Failure to Review and Update Cognitive Care Plans as Required
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed, updated, and revised for two out of three residents reviewed for care planning. Specifically, one resident with severe cognitive impairment and another with moderate cognitive impairment had care plans for impaired cognition that had not been reviewed or updated in accordance with the most recent comprehensive or quarterly assessments. The care plans contained goals and interventions, but there was no documented evidence that these were evaluated for effectiveness or that goals were met, as required by facility policy. Interviews with facility staff revealed that the responsibility for updating cognitive care plans typically falls to the Social Worker, who stated that updates are supposed to occur quarterly, annually, and with any significant changes. However, discrepancies were noted between the dates of care plan reviews in the electronic medical record and the actual care plan meeting documentation. The Social Worker and DON acknowledged that care plan updates were not consistently reflected in the system, and meeting notes were not always properly transferred to the care plan documents.