Failure to Complete Comprehensive Resident Assessments and Care Plans
Penalty
Summary
The facility failed to conduct comprehensive, accurate, and timely assessments for two residents, as required by regulation. For one resident with chronic obstructive pulmonary disease, chronic ischemic heart disease, and cellulitis, the Minimum Data Set and care plan did not address the presence of edema or cellulitis, despite these conditions being observed and mentioned in the baseline care plan. Medication and treatment administration records also lacked documentation for these issues, and the resident reported that staff rarely addressed their edematous legs, which were visibly swollen and sometimes weeping. For another resident with dementia, diabetes, and hypertension, the baseline care plan contained multiple prompts regarding skin integrity, medical diagnoses, antibiotic use, presence of an ostomy, and other care needs, but none of these prompts were completed. There was no documentation confirming the presence of an ostomy, and the comprehensive care plans for skin integrity, psychosocial well-being, and nutrition did not address all relevant conditions or risks, such as the risk for pressure sores or ostomy care. Interviews with nursing staff revealed that assessments and care plans were incomplete due to staffing shortages and workload issues. One nurse stated that they were responsible for multiple roles, including medication administration and direct care, which limited their ability to complete thorough assessments and care plans as required.