Failure to Develop Comprehensive Care Plan Following MDS Assessment
Penalty
Summary
The facility failed to develop a comprehensive care plan within seven days of completing the Minimum Data Set (MDS) assessment for one resident. According to facility policy, the care plan should be developed within seven days of the required MDS assessment and no more than 21 days after admission. For the resident in question, who was admitted with diagnoses including hypertension, thyroid disorder, cerebral infarction (stroke), and neuropathy, the MDS identified significant care needs such as dependence on staff for toileting, bathing, transfers, wheelchair mobility, dressing, and personal hygiene. Despite the MDS and Care Area Assessments (CAAs) indicating the need for care planning in areas such as cognition/dementia, communication, functional abilities, urinary incontinence, psychosocial, behavior, falls, dental, and pressure ulcers, the comprehensive care plan only addressed transfers under functional abilities. There were no interventions listed for cognition/dementia, communication, urinary incontinence, psychosocial, or dental needs. The MDS Coordinator confirmed these omissions and acknowledged that additional interventions should have been included for the resident's identified needs.