Failure to Revise and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement and revise comprehensive care plans for two residents with significant care needs. For one resident with dementia and adult failure to thrive, the care plan was not updated to reflect the resident's increased need for substantial or maximal assistance with eating, despite a significant change in condition documented in the MDS assessment. Staff continued to document the resident as eating independently, and multiple observations showed that the resident was not provided with the necessary assistance during meals. Interviews with staff and the MDS Coordinator confirmed that the care plan did not accurately reflect the resident's current needs, and staff were not consistently providing the required level of assistance. For another resident with chronic kidney disease and dependence on renal dialysis, the care plan was not revised to remove a fluid restriction after the physician's order for the restriction was discontinued. The care plan continued to indicate that the fluid restriction was in place, even though the order had been stopped. The MDS Coordinator acknowledged that the care plan should have been updated to reflect the change in the resident's treatment orders.