Failure to Revise Care Plan for Resident with Exploitation History and Changing Needs
Penalty
Summary
The facility failed to review and revise the care plan for a resident with a history of exploitation, cognitive impairment, and multiple medical conditions, including dementia, diabetes, and COPD. Despite documentation on the resident's face sheet indicating that only a specific family member with power of attorney was authorized to take the resident out of the facility, the care plan did not address the resident's history of exploitation, potential for elopement, or include interventions to reduce the risk of future exploitation. There were also no instructions regarding visitor restrictions or interventions to address concerns of elopement, and the resident's mental health needs and feelings about his restrictions were not included in the care plan. The care plan contained a discharge plan with a goal for the resident to return to the community, which was not updated or revised to reflect the family's clear communication that the resident's placement was intended to be permanent. Multiple quarterly and comprehensive MDS assessments were completed, but the care plan was not updated following these assessments to reflect the resident's current needs or changes in discharge planning. Progress notes documented incidents where unauthorized individuals attempted to remove the resident from the facility, and the family member reiterated the need for strict visitor and outing restrictions due to the resident's vulnerability and history of exploitation. Interviews with facility staff, including the BOM, LVNs, SW, Administrator, DON, and MDS Coordinator, revealed a lack of awareness regarding the resident's history of exploitation, visitor restrictions, and discharge plans. Staff were either unaware of where such information would be documented or unfamiliar with the resident's specific needs. The facility's policy required comprehensive, person-centered care plans to be reviewed and revised after each MDS assessment, but this was not followed in the resident's case, resulting in the failure to address and communicate critical safety, mental health, and nursing needs.