Failure to Revise Care Plan After Discontinuation of Special Equipment
Penalty
Summary
Facility staff failed to revise the comprehensive care plan for a resident following the discontinued use of a voice amplifier. The resident, who was admitted with diagnoses including muscle weakness and had moderate cognitive impairment as indicated by a BIMS score of 11 out of 15, had a physician's order for the use of a voice amplifier and charger to be managed by nursing staff. The care plan, last revised several months prior, still included interventions for the use of the voice amplifier, despite the resident no longer using the device. Interviews with facility staff revealed that the speech therapist confirmed the resident did not want to use the voice amplifier after trying it in therapy, and the device was not being used. The MDS coordinator acknowledged that the care plan should have been reviewed and revised to reflect this change. The facility's policy requires care plan revisions upon a resident's status change, but this was not followed in this instance, resulting in the care plan not being updated to reflect the discontinued use of the voice amplifier.