Failure to Revise Comprehensive Care Plans After Changes in Resident Status
Penalty
Summary
The facility failed to revise the comprehensive care plans for three residents following changes in their conditions or care needs, as required by facility policy and federal regulations. For one resident with diagnoses including metabolic encephalopathy, COPD, diabetes, and depression, the quarterly MDS assessment indicated a change in personal hygiene needs from requiring supervision/touch assistance to being dependent on staff. However, the care plan was not updated to reflect this increased dependency, and the MDS Coordinator confirmed the care plan remained outdated. Another resident with multiple diagnoses, including pneumonia, diabetes, severe obesity, dementia, and dysphagia, experienced significant weight loss as identified in a quarterly MDS assessment. Despite this, the resident's care plan was not revised to address the actual weight loss, and this was confirmed by both the DON and the Regional Director of Clinical Reimbursement. The care plan continued to reference risk factors without incorporating the new information about the resident's weight loss. A third resident, with diabetes, hemiplegia, and an acquired absence of toes, was ordered to use off-loading boots while in bed to prevent skin breakdown. Observations and interviews confirmed the resident consistently wore the boots, but the care plan was not updated to include this intervention. Facility staff, including the MDS Nurse and ADON, acknowledged that the care plan should have been revised to reflect the new physician order and the resident's current care needs.