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 four residents as required by policy. For one resident, no Minimum Data Set (MDS) was completed after admission, resulting in the absence of a care plan with interventions to guide care for 26 days. Another resident receiving hospice services did not have a completed MDS or baseline care plan, with MDS assessments overdue by up to 18 days. A third resident's quarterly MDS was not completed, and although a care plan was eventually initiated, it was delayed and only addressed certain risks such as skin breakdown, falls, and pain. The fourth resident, with multiple medical diagnoses including malignant neoplasm, also did not have a completed MDS or comprehensive care plan at the time of review. Interviews revealed that the Director of Nursing (DON) was responsible for care plans, fall assessments, and MDSs, but these duties were not reassigned after the DON position became vacant. As a result, some residents only had limited care plans addressing basic needs such as transfers, incontinence, or eating, rather than comprehensive plans derived from thorough assessments. These findings were based on observations, interviews, record reviews, and facility document reviews.