Failure to Update Care Plan to Reflect Improved ADL and Mobility Status
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect the resident’s current functional status, as required by facility policy and federal regulations. The facility’s care plan policy, dated December 1, 2025, required each resident to have an individualized, person-centered, comprehensive plan of care with measurable goals and timetables, and directed that the interdisciplinary team review care plans at least quarterly and update them with any significant change in condition. Record review showed that one resident’s care plan, last revised on November 1, 2024, continued to document a need for assistance of one staff member for bed mobility, positioning, turning, oral care, dressing, and transfers between surfaces, and assistance of two staff members for moving between lying and sitting positions. However, the resident’s MDS assessment identified that the resident had no impairment of upper or lower extremities and was independent with oral hygiene, upper and lower body dressing, bed mobility, sit-to-stand, toilet transfers, and wheelchair mobility. The facility did not update the care plan to reflect this improvement in physical mobility and ADL status, and an administrative staff member confirmed that staff failed to revise the care plan to match the resident’s current functional ability. This failure limited staff’s ability to communicate needs and ensure continuity of care.
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