Failure to Update Care Plan After Significant Change Assessment
Penalty
Summary
The facility failed to update the care plan for one resident following a Significant Change of Status Assessment (SCSA), as required by federal guidelines. The resident, who had a history of pulmonary fibrosis and was re-admitted to the facility, experienced an improvement in their condition that was not reflected in the revised care plan dated 1/25/25. A review of the clinical chart showed that the care plan for activities of daily living (ADL) did not include updated information from the SCSA regarding the resident's improvement. Interviews with facility staff revealed that the MDS nurse acknowledged the required assessments, including the MDS and CAA, were not completed on time, and the care plan was not updated to reflect the resident's improved self-care abilities. The DON confirmed the importance of timely completion of these assessments and care plan updates to ensure they reflect the resident's current condition. The facility's policy also requires the interdisciplinary team to review and update care plans when there is a significant change in a resident's condition.