Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to the lack of measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. For one resident with severe cognitive impairment and a diagnosis of dementia, the facility did not include the resident's hospice status as a focus area in the comprehensive care plan, despite documentation indicating coordination with hospice services and selection of hospice care in the MDS assessment. There was no care plan intervention in place to address the resident's hospice needs, and physician orders for hospice services were not reflected in the resident's records at the time of review. Another resident, who was cognitively intact but dependent on staff for activities of daily living (ADL) due to multiple chronic conditions including end stage renal disease, hypertension, atrial fibrillation, and coronary artery disease, did not have ADL care addressed in the comprehensive care plan. The care plan was not completed to include the resident's ADL needs, despite the resident requiring one to two staff for assistance. Interviews with facility staff confirmed that the care plans were incomplete and not in accordance with facility policy, which requires comprehensive, person-centered care plans to be developed within a specified timeframe after admission or completion of the MDS assessment. The facility's policy states that care plans must include measurable objectives, timeframes, and describe the services to be furnished to attain or maintain the resident's highest practicable well-being. However, the care plans for both residents lacked these essential components, and staff acknowledged that the absence of complete care plans could result in residents not receiving all appropriate care from staff. The findings were based on record reviews and staff interviews, which confirmed the deficiencies in care planning for the affected residents.