Failure to Update Care Plans Following Changes in Resident Status
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for two residents following changes in their clinical status. For one resident with chronic respiratory failure, morbid obesity, and obstructive sleep apnea, the care plan continued to reference CPAP use and resistance to CPAP, despite the resident no longer having a CPAP order due to ongoing refusals. The resident confirmed that the CPAP had not been picked up and was not in use, and the MDS coordinator acknowledged that the care plan should have been updated to reflect this change. For another resident with congestive heart failure, diabetes mellitus type 2, and dysphagia, the care plan indicated dependence on tube feeding, even though the resident's current physician orders reflected a regular puree diet and only maintenance flushes for the PEG tube. The MDS coordinator confirmed that the care plan should have been revised to indicate that the resident was no longer dependent on tube feedings. In both cases, the facility's policy required care plans to be updated when outcomes were not met and at least quarterly, but this was not done.