Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident following admission. The resident was admitted with multiple diagnoses, including dementia, Alzheimer's dementia, acute kidney failure, urinary tract infection, atrial flutter, diverticulosis, diabetes mellitus type 2, and general anxiety disorder. Review of the electronic health record revealed that the care plan only included two focus areas: advanced directives and long-term residency, with no evidence of a complete or dated care plan. Staff interviews confirmed that the care plan was never fully developed, and any baseline care plan that may have existed was not accessible to staff for guiding care. The Director of Nursing and the Care Plan Coordinator both acknowledged the absence of a comprehensive, individualized care plan for the resident after admission.