Failure to Update Care Plan After Resident Transfer
Penalty
Summary
The facility failed to update and revise the individualized, person-centered care plan for one resident following a significant change in the resident's care environment. The resident, who had severe cognitive impairment with a BIMs score of 1 out of 15 and diagnoses including dementia, anxiety, and depression, was observed resting in bed on the 300-unit hall with a perimeter mattress and bilateral fall mats. Despite being moved from the secure dementia unit (100-unit hall) to the 300-unit hall on July 17th, the resident's care plan continued to state that the resident resided on the secure care unit for a therapeutic environment related to dementia. This discrepancy was identified during a survey through observation, interview, and record review. The LPN managing the 300-hall unit confirmed that the care plan had not been updated to reflect the resident's new location and care needs, despite the facility's policy requiring comprehensive, person-centered care plans to be developed, implemented, and revised as needed. The failure to update the care plan resulted in the potential for unmet care needs for the resident.