Failure to Timely Assess and Update Care Plan After Resident's Significant Change in Condition
Penalty
Summary
The facility failed to properly assess and document a significant change in condition for a resident who was re-admitted with a history of pulmonary fibrosis. Despite evidence of improvement in activities of daily living (ADLs) such as eating, oral hygiene, and toileting, the Interdisciplinary Team (IDT) did not review or determine the need for a Significant Change of Status Assessment (SCSA) during the comprehensive skilled review. The Minimum Data Set (MDS) nurse confirmed that the SCSA was not discussed or initiated in a timely manner, and the care plan was not updated to reflect the resident's improvement as required by the Resident Assessment Instrument (RAI) manual. Additionally, the care plan for the resident's ADLs, last revised prior to the improvement, did not include updated information from the SCSA. The MDS nurse also stated that the resident's physician was not notified of the improvement, and the IDT did not solidify whether an SCSA was appropriate during their review. The Director of Nursing indicated that the expectation was for the IDT and MDS nurse to know and apply the criteria for SCSA and to discuss significant changes in status for all residents, but this did not occur in this instance.