Failure to Timely Revise Care Plan After Discontinuation of Contact Precautions
Penalty
Summary
The facility failed to ensure that a resident’s comprehensive person-centered care plan was reviewed and revised in a timely manner when the resident’s condition and orders changed. Facility policy required that resident assessments be ongoing and that care plans be revised as resident information and conditions change, as well as reviewed and updated at least quarterly in conjunction with required quarterly MDS assessments. The resident had diagnoses including dementia and pressure ulcers to both heels and had been placed on Contact Precautions, which were reflected in a care plan focus for wound infection and Contact Precautions dated October 28, 2025. Physician orders for this resident discontinued Contact Precautions on November 1, 2025, and the clinical record showed a Significant Change Comprehensive MDS completed on November 17, 2025, and a Quarterly MDS completed on December 3, 2025. Despite these changes and required assessments, the care plan continued to list Contact Precautions and was not revised to reflect the discontinued orders until February 9, 2026. During an interview, the DON confirmed that Contact Precautions had been discontinued on November 1, 2025, and acknowledged that the care plan was not revised until February 9, 2026, although she would have expected it to be updated when the orders changed or at least at the time of the MDS assessments.
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