Failure to Timely Update Comprehensive Care Plan After Assessment
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days after the completion of the comprehensive assessment for one resident. Record review showed that the resident, a male with diagnoses including severe dementia with mood disturbances, major depressive disorder, type 2 diabetes mellitus, hypertension, and generalized anxiety disorder, had an annual MDS assessment completed, but the care plan was not updated or revised within the required timeframe. The care plan on file had a start and completion date prior to the most recent MDS assessment, and there was no evidence of an update following the assessment. Interviews with facility staff confirmed that it was the responsibility of the MDS LVN to ensure care plans were timed correctly with MDS assessments, and that failure to update the care plan could result in the resident not receiving appropriate care. The DON also acknowledged that the care plan should have been updated within 7 days of the MDS completion and that not doing so leads to inaccurate care plans. Facility policy requires that comprehensive care plans be developed within 7 days after completion of the comprehensive assessment and be reviewed and revised after each MDS assessment.