Failure to Update Care Plan Following Resident Decline
Penalty
Summary
The facility failed to update the care plan for a resident who experienced a significant decline in functional status and was placed on hospice care. Despite a comprehensive assessment indicating that the resident now required substantial or maximal assistance with eating, the care plan continued to reflect only a need for supervision or limited staff participation, as originally documented several years prior. Staff observations showed the resident sitting up in bed, slowly feeding themselves, and expressing a desire for help, yet no assistance was provided during the meal. Interviews with staff revealed a lack of awareness regarding the resident's current needs, with one CNA stating they were unaware the resident required feeding assistance and another staff member indicating that queuing and supervision were believed to be sufficient. The MDS coordinator acknowledged that the care plan should have been updated following the significant change assessment but had not been revised. The administrator confirmed that care plans are expected to be current and that staff should provide assistance as needed.