Failure to Review and Revise Care Plans After Assessments and Changes in Condition
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, as well as change of condition assessments. For two residents whose care plans were reviewed, the care plans did not reflect current diagnoses, treatments, or needs. One resident, with diagnoses including unspecified dementia and COPD, was admitted to hospice care and prescribed morphine for pain management, but the care plan was not updated to include these significant changes. The care plan for this resident had not been reviewed or revised since several months prior to the change in condition and new orders. Another resident, with diagnoses including unspecified dementia, type 2 diabetes, coronary artery disease, hypertension, anxiety, and depression, had a quarterly MDS assessment indicating new or ongoing conditions and medications, such as hypertension and a new order for amlodipine. However, the care plan for this resident had not been reviewed, revised, or edited in over a year and did not address the current diagnosis of hypertension or the associated medication. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans, especially in the absence of a dedicated MDS nurse. The social worker and ADON were unsure who was responsible for care plan updates, and the regional MDS nurse confirmed that care plans had not been reviewed or updated as required. Facility policy required care plans to be developed and revised based on ongoing assessments and changes in resident condition, but this was not followed for the residents reviewed.