Failure to Update Care Plan After Loss of Hearing Aids
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for a resident with significant hearing loss and cognitive impairment. The resident, who had a history of dementia, Alzheimer's disease, depression, and muscle weakness, experienced a significant change in her cognitive status as reflected in her MDS assessments. Despite the loss of her hearing aids, which were documented as missing and not replaced due to repeated losses, the care plan was not updated to reflect new communication strategies or interventions to address her hearing deficit. Multiple assessments and interviews revealed inconsistencies and inaccuracies in the documentation of the resident's cognitive and communication abilities. The resident's BIMS scores declined significantly after the loss of her hearing aids, and staff interviews confirmed that the resident had difficulty hearing and communicating without them. Staff began using a whiteboard to facilitate communication, but this intervention was not documented in the care plan, nor was it communicated to all relevant team members. The care plan continued to reference the use of hearing aids and did not include alternative communication methods after the aids were lost. Interviews with staff, including the DON, MDS nurse, social worker, and therapy staff, confirmed that the loss of the hearing aids and the use of alternative communication methods were discussed in meetings but not formally incorporated into the care plan. The facility's policies required care plans to be updated promptly after significant changes in a resident's condition, but this was not done in this case. As a result, the resident's current needs and effective interventions were not accurately reflected in her care plan, potentially impacting the quality of care provided.