Failure to Revise Care Plan After Resident's Decline and Change in Condition
Penalty
Summary
The facility failed to revise the care plan for a resident after significant changes in her condition and care needs, as required by regulation and facility policy. Initially, the resident was assessed as independent in most activities of daily living (ADLs), including dressing, eating, personal hygiene, toilet use, and transfers. However, over the course of her stay, the resident experienced multiple hospitalizations, falls, and a decline in functional status, resulting in increased dependence on staff for ADLs and the need for mechanical lift assistance for transfers. Despite these changes, the care plan was not updated to reflect her increased care needs, new therapy orders, or the implementation of a home exercise program recommended by physical therapy. Medical records and staff interviews revealed that the resident's condition deteriorated significantly, with new diagnoses including metabolic encephalopathy, heart failure, neuropathy, and essential tremor. She became dependent on staff for toileting, bathing, dressing, and transfers, and required maximum assistance or mechanical lift for mobility. Orders for rehabilitation services and therapy were not processed or incorporated into the care plan, and goals related to pain management and functional improvement were not added. Staff members were inconsistent in their understanding and implementation of the resident's care needs, with some unaware of her current status or the interventions required. Interviews with nursing staff, therapy staff, and administration confirmed that the care plan had not been revised since the resident's admission, despite multiple significant changes in her condition and care requirements. The RAI coordinator acknowledged not updating the care plan after completing the MDS assessment, citing inexperience. Other staff members were unaware of therapy orders or failed to document education and interventions related to the resident's noncompliance and deconditioning. The facility's policy required care plans to be updated after significant changes, but this was not followed in the resident's case.