Failure to Timely Update and Review Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure the timely development, review, and revision of person-centered, comprehensive care plans for five residents. Record reviews showed that for each of these residents, the last quarterly care plan was not completed in accordance with the required schedule, despite recent comprehensive MDS assessments being performed. Interviews with the Administrator, DON, and MDS Coordinator confirmed that care plans were not updated quarterly as required, and that the DON was responsible for this process. The facility's policy also requires the interdisciplinary team to review and update care plans at least quarterly, in conjunction with the required MDS assessment. Direct observations and interviews revealed that the lack of updated care plans could result in staff not having current information on the care needs of residents. The Administrator and DON acknowledged the oversight and confirmed that the care plans for the affected residents were outdated. The MDS Coordinator further clarified that care plans should be updated upon admission, quarterly, and with any change in condition, and that these should be accessible to staff. The deficiency was identified through interviews and record reviews, which demonstrated that the facility did not follow its own policy or regulatory requirements for care plan updates.