Failure to Complete Comprehensive Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident within the required timeframe. The resident, an elderly female with diagnoses including COPD, dementia, diabetes type 2, HTN, and hypothyroidism, was admitted and only received a baseline care plan at admission. The comprehensive care plan, which was due within 21 days of admission and 7 days after the comprehensive assessment, was not completed. Review of care plan records confirmed that only the baseline care plan was present, and no updates or comprehensive plan had been made by the due date. Interviews with facility staff, including the MDS coordinator, LVN, CNA, DON, and ADM, revealed a lack of awareness regarding the requirement to complete a comprehensive care plan within the specified timeframe. Staff acknowledged the importance of care plans in guiding resident care and preventing negative outcomes, but the responsible staff member was unaware of the 21-day requirement. Facility policy also confirmed the expectation for timely development of comprehensive, person-centered care plans based on thorough assessment.