Failure to Review and Revise Comprehensive Care Plan After Required Assessments
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by the interdisciplinary team after each required assessment for a resident. Specifically, the resident's comprehensive care plan was not reviewed or updated following both a quarterly and an annual Minimum Data Set (MDS) assessment, despite the resident having multiple complex diagnoses including Alzheimer's disease with early onset, vascular dementia, schizoaffective disorder - bipolar type, Parkinson's disease, and hallucinations. The last documented review and update of the resident's care plan occurred several months prior to these assessments. Interviews with facility leadership revealed that the care plan should have been updated after each MDS assessment, but this did not occur. The facility had recently transitioned between electronic health record (EHR) systems, and during this period, some records were managed manually. Despite this, no updated care plan could be located for the resident. Staffing changes, including the termination of the prior MDS coordinator and reliance on part-time and regional coordinators, were also noted, but the MDS coordinators had full access to the EHR and were responsible for care plan updates.