Failure to Revise Care Plans Following Changes in Resident Needs
Penalty
Summary
The facility failed to revise the care plans for two residents as required by both facility policy and regulatory standards. For one resident with dementia, diabetes, and hypothyroidism, the care plan indicated the use of a night light, but observations on multiple occasions revealed that a night light was not present in the room. The DON confirmed that the night light had been discontinued, but the care plan was not updated to reflect this change. This demonstrates a lack of timely care plan revision following a change in the resident's care needs. For another resident with Alzheimer's disease, dementia, and abnormal weight loss, the care plan stated the resident could eat independently with setup, cues, and oversight. However, both staff interviews and direct observation showed that the resident required total assistance with eating. An occupational weight loss screen and a BIMS assessment also indicated severe cognitive impairment and dependence on staff for eating. The MDS coordinator confirmed that the care plan had not been revised to accurately reflect the resident's current need for eating assistance.