Failure to Revise Care Plans to Reflect Current Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to revise and update comprehensive care plans to reflect residents’ current needs and interventions following changes in condition or care. For one resident with chronic pulmonary edema and an open right foot wound, the resident reported having fallen multiple times, with the most recent fall occurring when he slid off his recliner onto the floor. The medical record contained a progress note documenting the fall, and the resident stated the facility had provided him with a different recliner. However, review of the resident’s care plan showed no documented interventions related to the recent fall, no inclusion of the need for a spacer with the recliner, and no documented interventions related to the resident’s right adaptive shoe use. The MDS RN confirmed the care plan should have been revised to include these needs and had not been. A second resident, with diagnoses including paranoid schizophrenia and chronic kidney disease, was observed with his bed positioned very low to the ground, and he stated this made it easier for him to get out of bed. Review of this resident’s care plan showed that the use of a low bed position was not documented as an intervention. The MDS RN stated that the low bed position should have been included in the care plan and was not. The survey findings concluded that the facility did not ensure care plans were revised to reflect current needs and interventions for these residents, placing them at risk for adverse outcomes if care and services were not provided due to outdated care plans.
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