Failure to Review and Revise Comprehensive Care Plan After MDS Assessment and Readmissions
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was reviewed and revised following the completion of a scheduled Quarterly Minimum Data Set (MDS) assessment, as required by facility policy. The policy states that the Interdisciplinary Team (IDT), in conjunction with the resident and their family or legal representative, must review and revise the care plan at least quarterly, upon significant changes in condition, when desired outcomes are not met, and upon readmission. Despite the completion of a quarterly MDS assessment and multiple hospital readmissions, there was no documentation that the care plan had been reviewed or updated for this resident during a six-month stay. The resident involved had complex medical needs, including metastatic anaplastic thyroid cancer requiring a tracheostomy and gastrostomy tube, chronic pulmonary embolism, and deep vein thrombosis. Interviews with MDS nurses and the DON revealed that they were unaware the care plan had not been reviewed or revised as required. The expectation, as stated by staff, was that care plans should be reviewed and revised after each comprehensive MDS and upon readmission, but this did not occur for the resident in question.