Failure to Update Comprehensive Care Plan After MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to develop, review, and revise a comprehensive, person-centered care plan within seven days of the comprehensive assessment and after subsequent MDS assessments, as required. For one resident, the comprehensive care plan dated 03/20/25 listed an ADL self-care performance deficit and a regular diet with the option of a divided plate, but did not include that the resident required moderate assistance with eating or that she was on a mechanically altered diet with specific nutritional interventions. The facility’s own policy stated that the resident’s care plan would be reviewed after each admission, quarterly, annual, and/or significant change MDS assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. The resident involved was an older female with multiple diagnoses, including fractures of the left femur and right radius, vascular dementia, Down syndrome, and bradycardia. Her quarterly MDS assessment showed she was sometimes understood, usually understood others, had a BIMS score of 0/15 indicating severely impaired cognition, required moderate assistance with eating, and was on a mechanically altered diet. Active orders reflected a regular diet with mechanical soft texture, magic cup with lunch, pureed meat with gravy, and the option for a divided plate. Observations confirmed she was receiving a mechanical soft diet and assistance with eating at meals, and had a magic cup at lunch, but these needs and interventions were not reflected in the comprehensive care plan. During interviews, the MDS RN acknowledged not knowing why these needs and orders were missing from the care plan and stated it should have been reviewed and revised after the last comprehensive assessment, while the DON and interim administrator affirmed that the care plan needed to accurately reflect the care required and be reviewed and revised by the team after MDS assessments.
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