Inaccurate Care Plan Diagnosis and Interventions for Thyroid Condition
Penalty
Summary
The facility failed to develop and implement an accurate, comprehensive person-centered care plan for a resident by listing an incorrect diagnosis and related interventions. The resident, an older female admitted with conditions including cerebral infarction, GERD, and hypothyroidism, had a face sheet and provider note documenting a diagnosis of hypothyroidism. However, the resident’s care plan dated 3/13/2025 incorrectly identified hyperthyroidism instead of hypothyroidism and included interventions tailored to hyperthyroidism, such as adjustment of lighting to prevent eye irritation, safety for altered mental status and altered muscle coordination, and encouraging periods of rest to reduce energy needs. The quarterly MDS assessment showed a BIMS score of 10, indicating moderate cognitive impairment and a need for moderate assistance with ADLs, and did not list either hypo- or hyperthyroidism as a diagnosis. Interviews with staff revealed gaps in the care planning and review process that contributed to the deficiency. The MDS Coordinator, responsible for MDS assessments and care plans, stated that any licensed charge nurse or management team member could change a care plan and that care plans were discussed in morning meetings and reviewed with quarterly assessments. He acknowledged that the resident’s care plan incorrectly listed hyperthyroidism and that the interventions were not all appropriate for hypothyroidism, explaining that the care plan had been created by an LVN who no longer worked at the facility and that the error was not identified during subsequent reviews, including the last review on 1/14/2026. The DON stated that important care plan items are added on admission by various team members and that active diagnoses are entered by the MDS nurse after the MDS assessment, which she is supposed to review for accuracy. She reported that she did not review this resident’s MDS assessment, despite recognizing that accurate care plans are important for accurate care.
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