Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was admitted for short-term managed care rehabilitation following hospitalization for weakness related to a recent COVID-19 infection and chemotherapy for cancer. The resident also had unstageable sacral wounds and a history of depression, anxiety, and pain. Despite the completion of a Minimum Data Set (MDS) assessment, the medical record review revealed that only a single-page, incomplete care plan was initiated after the resident's discharge, which included just one intervention related to skin integrity and was subsequently canceled. No evidence was found of a comprehensive care plan being created during the resident's stay. Interviews with facility leadership, including the DON and NHA, confirmed that no comprehensive care plan was developed for the resident. The DON acknowledged the absence of the care plan and provided only the incomplete document to the surveyor. The NHA also confirmed awareness of the deficiency and clarified that no attempt was made to create documentation after the resident's discharge. The facility's policy required a comprehensive care plan to be developed within seven days after the MDS assessment, but this was not followed in the resident's case.