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F0744
D

Failure to Implement Dementia Care Plan

Pittsburgh, Pennsylvania Survey Completed on 02-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement individualized person-centered care plans for a resident diagnosed with dementia, as required by their own "Dementia-Clinical Protocol" policy. This policy mandates that the interdisciplinary team should create a care plan to maximize the resident's remaining function and quality of life. Despite the resident's admission to the facility with a diagnosis of dementia, anxiety, and depression, and the subsequent assessment confirming the dementia diagnosis, the facility did not create a care plan addressing these needs. The deficiency was confirmed through a review of the resident's clinical records and interviews with facility staff. The records from the resident's admission date through the survey date showed no evidence of a person-centered care plan for dementia. Interviews with a Licensed Practical Nurse and the Vice President of Clinical Services corroborated the absence of such documentation, confirming the facility's failure to meet the regulatory requirement for individualized care planning for dementia.

Plan Of Correction

Resident R35's care plan has been updated by nursing to include dementia related services. Current residents with dementia will be reviewed by the Director of Nursing (DON) / designee to ensure their care plans are comprehensive. Reeducation will be provided by the DON to all licensed nursing staff that all residents with dementia must have a care plan for related services. The DON / designee will monitor all new admissions, readmissions, resident's change in condition, and quarterly care plans to ensure care plans are developed and implemented for each resident to include dementia related services daily for 3 weeks, then 3 times a week for 3 weeks, and then randomly thereafter.

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