Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as identified in their comprehensive assessments. Resident 20, who has diagnoses including legal blindness, hearing loss, difficulty walking, and an enlarged prostate, was noted in the Minimum Data Set (MDS) assessment to have vision difficulties, communication issues due to impaired hearing, and continence issues. However, there was no evidence that interventions for these issues were included in the care plan. Similarly, Resident 56, with diagnoses of difficulty walking and heart failure, was identified in the MDS Care Area Assessment (CAA) summary to have incontinence issues that needed to be addressed in the care plan. Despite this, there was no evidence that interventions for urinary incontinence were included in the current care plan. The Assistant Director of Nursing confirmed the absence of documented evidence addressing these care areas in the care plans.