F0657

D

Failure to Update Care Plan for Changing Discharge Planning Needs

Emmett, Idaho Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident’s comprehensive care plan was revised to reflect current discharge planning needs and goals as required by CMS SOM Appendix PP and the facility’s RAI & Comprehensive Care Plans Policy and Procedure. The policy, revised on 9/3/25, required that the care plan reflect discharge planning goals, and CMS guidance required review and revision of the care plan after each assessment based on changing goals, preferences, and needs. Resident #1, initially admitted and later readmitted with multiple diagnoses including chronic kidney disease, peripheral venous insufficiency, and morbid severe obesity, had a care plan initiated on 3/1/24 and revised on 9/29/25 that documented the resident wanted to stay at the facility long term. However, the care plan was not updated to include current discharge planning that reflected the resident’s evolving goals, preferences, and care needs. During an interview on 2/3/25 at 2:00 PM, the MDS Nurse acknowledged that there was no updated care plan reflecting discharge planning and stated that because the resident’s discharge plan kept changing, she chose not to update the care plan. This deficient practice created the risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents’ needs changed.