Failure to Revise Care Plan After Quarterly Assessment
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan following a quarterly assessment, as required by policy and regulation. Specifically, after a quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/25/2025, the care plan for a resident with Huntington's Disease, altered mental status, cognitive communication deficit, and a history of repeated falls was not updated to reflect a history of a nasal fracture. The care plan continued to list an active diagnosis of an acute non-displaced fracture at the tip of the nasal bones, which had been initiated and last revised prior to the quarterly assessment. Interviews with MDS staff confirmed that the care plan should have been revised after the quarterly MDS to accurately reflect the resident's current status, but this was not done.