Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident diagnosed with dementia. Record review showed that the resident was admitted with multiple diagnoses, including dementia, hypertension, and acute kidney failure. The Minimum Data Set assessment indicated the resident had severe cognitive impairment and required substantial to maximal assistance with most activities of daily living, such as eating, hygiene, and dressing. Despite these needs, there was no care plan addressing the resident's dementia diagnosis. During an interview, the DON confirmed that care plans are required for all residents, especially for those with high-risk diagnoses like dementia, to guide staff in providing appropriate interventions. The DON acknowledged that the absence of a dementia-specific care plan could result in staff not knowing the necessary interventions for the resident. Review of the facility's policy indicated that the interdisciplinary team is responsible for creating a resident-centered care plan for individuals with confirmed dementia, but this was not done for the resident in question.