Failure to Develop and Update Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents, specifically neglecting to address their vision, activities, and pressure ulcer risks. For one resident, the care plan was not revised or updated to include interventions and goals related to vision, despite documentation indicating vision impairment and risk for pressure ulcers. The Minimum Data Set (MDS) and Care Area Assessment (CAA) summaries identified these issues, but the care plan did not reflect them. For the second resident, the care plan lacked documentation and interventions for visual function, activities, and pressure ulcers, even though the resident's assessments indicated impaired vision, use of corrective lenses, and risk for pressure ulcers. The relevant sections of the MDS were either incomplete or not addressed in the care plan, and the CAA summaries triggered concerns that were not care planned. Interviews with facility staff, including the Administrator, DON, and MDS Coordinator, confirmed that care plans are intended to be individualized and updated based on assessments and resident needs. However, the care plans for these residents were not updated or individualized as required, and the facility's policy mandates that care plans include measurable objectives, timeframes, and interventions for all identified needs.