Failure to Update Care Plan After MDS Assessment
Penalty
Summary
Facility staff failed to thoroughly evaluate and revise a resident's care plan following each Minimum Data Set (MDS) assessment to ensure it accurately reflected the resident's current needs and interventions. Specifically, a resident with a spinal cord injury and quadriplegia was assessed as fully dependent for self-care activities such as eating, oral hygiene, toileting, bathing, dressing, and personal hygiene during a quarterly MDS assessment. Despite this, the resident's care plan continued to list these activities as independent, which did not align with the resident's actual condition or the assessment findings. Observation and interviews confirmed that the resident required staff assistance for all self-care activities, including turning, bathing, and nail care. The discrepancy between the care plan and the resident's actual needs was acknowledged by the Director of Nursing, who confirmed that the care plan was inaccurate and did not reflect the resident's dependent status. This failure to update and revise the care plan after the MDS assessment resulted in a care plan that did not provide accurate guidance for staff regarding the resident's required level of care.