Failure to Review and Revise Care Plan to Reflect Accurate Advance Directive Status
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the development, review, and revision of comprehensive care plans. Specifically, the care plan for one resident was not reviewed quarterly as required, and the goal target date was set for approximately six months after the last revision, exceeding the 90-day interval mandated by facility policy. Additionally, the care plan was not updated to reflect the resident's current advance directive status, despite documentation in both the POLST and Physician Order Sheet indicating Do Not Resuscitate (DNR) status. Instead, the care plan continued to state 'Full Code,' which was inconsistent with the resident's documented wishes and physician orders. During interviews, the Director of Nursing confirmed that care plans should be reviewed quarterly or upon significant change, and acknowledged that the resident's care plan was inaccurate and overdue for review. The facility's policy requires care conferences for review and revision of care plans every 90 days or as needed, with the interdisciplinary team responsible for implementation. The failure to update and accurately reflect the resident's code status in the care plan represents a lapse in adherence to established procedures and documentation requirements.