Failure to Update Care Plan After Resident Decline in ADLs
Penalty
Summary
The facility failed to revise the comprehensive care plan (CCP) for one resident following a significant change in their condition. The resident, who had a history of falling, schizoaffective disorder, bipolar type, violent behavior, and chronic pain, was admitted to the facility and initially assessed as independent in activities of daily living (ADLs) such as eating, toileting, ambulation, dressing, and personal hygiene. However, after experiencing a fall that resulted in surgery and a subsequent hospital stay, the resident returned to the facility with a documented decline in ADLs, as evidenced by a Minimum Data Set (MDS) assessment and staff observations. Despite the updated MDS Section GG indicating the resident now required varying levels of assistance with oral hygiene, toileting, dressing, and personal hygiene, the CCP was not updated to reflect these changes. Staff interviews confirmed that the resident was receiving assistance with these ADLs, but the care plan continued to list the resident as independent. This failure to update the care plan was confirmed by the MDS Coordinator, indicating a lapse in the required review and revision process following a change in the resident's condition.