Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident 10, which addressed their individual needs as identified in the comprehensive assessment. Resident 10 was admitted with diagnoses including malnutrition, colitis, and dysphagia. The Minimum Data Set Care Area Assessment summary indicated that the resident's dehydration, fluid maintenance, and dental care should be addressed in the care plan. However, there was no evidence of interventions for these care areas in the current care plan. This deficiency was confirmed by the Director of Nursing during an interview, who acknowledged the lack of documented evidence addressing these care areas.
Plan Of Correction
A comprehensive care plan has been developed for Resident 10 to address individual resident needs as identified in a comprehensive assessment. A comprehensive care plan will be developed for any identified needs at the time of an MDS. RNAC will review CAA report with Nursing. RNACS & Nursing will be educated on the CAA & care plan process. Care Plan audit will be conducted based on the CAA reports to ensure all identified areas have been care planned x 4 weeks. Audit Findings to be reported to QAPI Committee.