Failure to Develop and Implement Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by regulatory standards. For the first resident, who had multiple diagnoses including dementia, metabolic encephalopathy, COPD, diabetes, chronic respiratory failure, end-stage renal failure, and hypertension, the admission Minimum Data Set (MDS) assessment did not identify any physical or verbal behaviors. However, the resident had a history of socially inappropriate behaviors, specifically sexually inappropriate behavior, which was not addressed in the care plan upon admission. The care plan was only revised later to include interventions for these behaviors, indicating a delay in recognizing and planning for the resident's needs as identified in the comprehensive assessment. For the second resident, who had diagnoses including COPD, multiple sclerosis, bipolar disorder, and legal blindness, the care plan did not address the resident's substance abuse history or related behaviors. Despite documentation in progress notes that the resident was involved in bringing drugs into the facility and had an incident requiring transfer to the emergency room due to drug use, there was no corresponding care plan to address these behaviors. The resident himself admitted to a history of heavy drug use and recent marijuana use, and staff were aware of the incident and the ongoing risk, but this was not reflected in the care planning process. Interviews with facility staff, including the DON and MDS Nurse, confirmed that care plans were not updated to reflect significant changes or incidents, such as the emergence of new behaviors or substance abuse. The staff acknowledged the importance of updating care plans to ensure all care needs and interventions are communicated and implemented, but in these cases, the care plans did not include measurable objectives or timeframes to address the identified needs. This failure to update and individualize care plans was inconsistent with facility policy and regulatory requirements, as outlined in the facility's own policies and the CMS RAI Manual.