Failure to Update Care Plan Following Change in ADL Status
Penalty
Summary
The facility failed to revise the comprehensive, person-centered care plan for one resident following changes in her activities of daily living (ADL) status. Record review showed that the resident was admitted with diagnoses including congestive heart failure, anxiety, and depression, and her most recent assessment indicated she was independent in most ADLs except for requiring some assistance with bathing. However, the care plan continued to list her as needing partial or moderate assistance with bathing, supervision for transfers, and assistance with toileting, despite her current ability to perform most tasks independently except for showering. Interviews with the resident and a corporate registered nurse confirmed that the care plan had not been updated to reflect the resident's current ADL abilities.