Failure to Update Care Plan for Cognitively Impaired Resident Requiring Assistance with Eating
Penalty
Summary
The facility failed to revise and update the care plan for a cognitively impaired resident who required substantial to maximum assistance with eating, following the resident's annual assessment. The resident, who had diagnoses including Alzheimer's Disease, Dementia, Muscle Weakness, Diabetes Mellitus, and was receiving palliative care, was assessed with a BIMS score of 3/15, indicating severe cognitive impairment. The Minimum Data Set (MDS) and interdisciplinary care conference notes documented that the resident required maximum assistance with activities of daily living (ADLs), including eating. However, a review of the resident's care plan did not reflect the required level of assistance for eating. Interviews with the Director of Nursing (DON) confirmed that the care plan should have been updated to match the MDS and care conference documentation, specifically to indicate the need for maximum assistance with eating. The facility's care plan policy required timely updates and revisions to care plans when there were changes in a resident's condition. Despite this policy, the care plan was not revised after the annual assessment, resulting in a failure to ensure the care plan accurately addressed the resident's needs.