Failure to Update and Revise Care Plans After Significant Changes
Penalty
Summary
Facility staff failed to review and update care plans in response to changes in residents' care needs for multiple residents. Specifically, staff did not revise care plans after significant events such as falls or notable weight loss, nor did they consistently update care plans on a quarterly basis as required by facility policy. For example, one resident experienced a fall that resulted in an emergency room visit, but the care plan was not updated with new interventions following the incident. Another resident experienced a 5.7% weight loss in one month, but the care plan was not updated to address this change until over a month later, and there was no physician order to monitor or address the weight loss. Additionally, care plans for two residents were not updated quarterly as required. Interviews with the administrator and DON confirmed that care plans should be updated after significant changes, quarterly, and annually, and that new interventions should be added after events such as falls or significant weight changes. Both acknowledged that the MDS Coordinator and nurses are responsible for these updates, and that the DON is responsible for auditing care plans to ensure compliance. The DON admitted there was no excuse for the oversight in not verifying that care plans were updated after significant changes or on a quarterly and annual basis.