Failure to Revise Care Plan After Hospitalization and Change in Condition
Penalty
Summary
The facility failed to revise the care plan by the interdisciplinary team after each assessment for a resident who experienced a significant change in condition. Specifically, after a resident was hospitalized for respiratory distress and subsequently returned to the facility, a comprehensive assessment (MDS) was completed. However, there was no documented evidence that the care plan was reviewed and revised to address the resident's need for continuous mechanical ventilation related to respiratory insufficiency following the post-hospitalization assessment. Record review and interviews confirmed that the care plan was not updated after the resident's return from the hospital, despite the resident's dependence on a mechanical ventilator via tracheostomy. The DON acknowledged that the care plan should have been reviewed and revised as required, but this was not done after the most recent assessment.