Failure to Update Care Plan After Resident Loss of Ambulation
Penalty
Summary
The facility failed to revise the care plan for a resident who was no longer ambulatory, resulting in the continued inclusion of a restorative nursing ambulation program in the care plan. The resident had severe cognitive impairment and was dependent on staff for transfers and bed mobility, with documentation from both medical and behavioral health professionals indicating that the resident had not been able to walk for an extended period. Despite this, the care plan continued to list ambulation with restorative aides as an intervention, and staff interviews confirmed that the resident had not ambulated for nearly a year. Multiple staff members, including trained medication assistants, restorative aides, registered nurses, and the DON, acknowledged that the resident was not receiving ambulation services and had not walked for a significant amount of time. The facility's policy required care plans to be reviewed and updated quarterly or with any change in resident condition, but this was not done in response to the resident's decline in mobility. The deficiency was identified through interviews and document review, which showed a lack of timely care plan revision to reflect the resident's current status.