Failure to Update Care Plan After Resident's Change in Condition
Penalty
Summary
Facility staff failed to update a comprehensive care plan for a resident following a significant change in condition. The resident, who had a history of diabetes, hypertension, chronic kidney disease, and a right tibial fracture, was observed to have new deficits including difficulty speaking, inability to complete sentences, and inability to lift her right arm. Despite these changes, the resident's Minimum Data Set (MDS) quarterly assessment did not reflect the new impairments, and no change of condition was documented. The Licensed Vocational Nurse/Director of Staff Development confirmed that the MDS was inaccurate and that the resident had shown a decline for about a month without an updated care plan. Further review revealed that the care plan had not been revised since before the resident's decline, and the facility's policy requiring care plan updates after a change of condition was not followed. Interviews with staff indicated that there were mechanisms in place to prompt care plan updates, such as notifications in the electronic health record when new therapies were added, but these were not utilized. The Chief Nursing Officer acknowledged that the care plan was not reviewed or updated after the resident's change in status, confirming non-compliance with facility policy.