Incomplete Care Area Assessments for Two Residents
Penalty
Summary
The facility failed to complete Care Area Assessments (CAAs) comprehensively for two residents upon admission. For one resident with diagnoses including heart failure, diabetes mellitus, and atrial fibrillation, the admission Minimum Data Set (MDS) assessment triggered seven care areas, but analysis of findings was only provided for nutritional status. The remaining six triggered areas—communication, functional abilities, urinary incontinence and indwelling catheter, falls, dehydration/fluid maintenance, and pressure ulcer/injury—lacked documentation describing the nature of the problems, root causes, contributing factors, risk factors, and reasons for care planning. Similarly, another resident with non-Alzheimer's dementia, anxiety disorder, and depression had nine care areas triggered, but only the nutritional status area was analyzed, leaving eight areas without comprehensive assessment. Interviews with the MDS Coordinator confirmed that the required analyses for the triggered care areas were not completed before submission of the MDS assessments for both residents. The MDS Coordinator acknowledged responsibility for the oversight and could not explain how the error occurred. The DON and Administrator both stated their expectations that all CAAs be individualized and completed comprehensively prior to submission, which was not done in these cases.