Failure to Update Care Plan for Dependent Resident's ADL Needs
Penalty
Summary
The facility failed to revise the care plan for a resident who was dependent with activities of daily living (ADL), specifically oral care and personal hygiene. According to the facility's policy, care plans must be reviewed and revised at a minimum upon admission, quarterly, and with any significant change in condition. Record review showed that the resident's most recent comprehensive assessment documented a need for full staff assistance with oral care and substantial/maximal assistance with personal hygiene. However, the resident's care plan, last revised nearly a year prior, only indicated the need for set-up assistance by one staff member for these tasks. Interviews with facility staff, including a CNA, Infection Preventionist/RN, and the DON, confirmed that the resident's care needs had changed and that the care plan should have been updated to reflect the increased level of assistance required. Staff described the difference between set-up assistance and full dependence, and acknowledged that the care plan did not match the resident's current needs as documented in the assessment. This discrepancy placed the resident at risk for unmet needs and inappropriate care planning.