Rule/Regulation Violated:
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f):
a. No later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition; and
Evidence/Findings:
Based on record review and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of two residents reviewed. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed.
Findings include:
1. Review of R2's medical record contained an incident report in May 2023 that revealed R2 fell and fractured left wrist. R2 was taken to the hospital and was treated for a fracture.
2. Review of R2's medical record revealed a written service plan dated May 7, 2023. The service plan revealed R2 to have Occupational Therapy twice a week. However, the service plan was not updated to reflect the status of the change in condition.
3. During an interview, E1 reported the OT stopped approximately two months ago and forgot to update the service plan. E1 acknowledged R's service plan was not updated after a significant change of condition.
Summary:
The following deficiency was found during the on-site compliance inspection conducted on September 20, 2023: