Failure to Update Care Plan After Significant Change in Condition
Penalty
Summary
The facility failed to revise a resident's care plan to reflect individualized needs following a significant change in condition. Specifically, a resident who was previously ambulatory with the use of a walker or wheelchair and required varying levels of assistance for daily activities became bedbound, as documented in a significant change MDS assessment. Despite this change, the care plan and care plan header continued to list interventions such as the use of a fall mat, encouragement to use a walker, and a wander guard, which were no longer appropriate for the resident's current condition. Physician's orders had also been updated to remove the wander guard due to the resident's bedbound status, but these changes were not reflected in the care plan accessible to staff. Observations revealed that the resident did not have a fall mat at the bedside and the call light was out of reach, with the resident unable to use it or recall its location. Interviews with staff indicated uncertainty about the resident's current needs and whether certain interventions, such as the fall mat, were still required. Nursing staff acknowledged that the care plan should have been updated to reflect the resident's significant change in condition and individualized interventions, but this had not occurred.