Failure to Revise Care Plans After Significant Change and MDS Assessment
Penalty
Summary
The facility failed to revise person-centered care plans for two residents following significant changes in their health status and after required assessments. For one resident, who was admitted under Hospice care with diagnoses including dementia, diabetes mellitus, epilepsy, and joint stiffness, the care plan continued to reflect Hospice interventions even after Hospice care was discontinued by physician order due to an improved prognosis. The care plan was not updated to reflect this change until it was discovered during a therapy session, despite the facility's policy requiring care plan revision after a change in condition. The resident's Minimum Data Set (MDS) assessment, which should have triggered a care plan review, was also not completed within the required timeframe. Another resident, admitted with hemiplegia, dementia, and contractures, had a care plan that addressed lower extremity joint mobility but did not include interventions for upper extremity range of motion (ROM) limitations, despite physician orders and therapy recommendations for both arms and legs. The resident's MDS assessment indicated functional ROM limitations in both arms and legs, but the care plan was not updated to address the upper extremity needs after the assessment was completed. The care plan had not been revised since a previous date, and the omission was confirmed during interviews and record reviews with staff. The facility's policy and procedure on comprehensive person-centered care planning required that care plans be reviewed and revised after changes in condition and following each MDS assessment. In both cases, the required interdisciplinary review and timely revision of care plans did not occur, resulting in care plans that did not accurately reflect the residents' current needs and interventions.