Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was admitted with diagnoses of dementia, diabetes mellitus, and heart failure. The resident's admission Minimum Data Set (MDS) assessment indicated moderate cognitive intactness, yet a review of the care plan system (PCC) revealed that no care plan was present for the resident as of the date of the survey. Interviews with the Director of Nursing (DON) and the MDS coordinator confirmed that a care plan should have been in place, with the MDS coordinator stating that the care plan was completed but may have been deleted from the system. The DON acknowledged that the care plan was necessary to ensure appropriate services and care were provided. Facility policy requires that a comprehensive care plan be developed within seven days of completion of the resident assessment (MDS). Despite this policy, the required care plan was not available in the system for the resident, and staff were unable to account for its absence. This lack of a documented care plan meant that the resident's individualized needs and services were not formally outlined or accessible to the care team.