Failure to Develop and Implement Comprehensive ADL Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, as required by regulatory standards. Specifically, the care plan did not include measurable objectives and timeframes to address the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. The care plan was missing critical information regarding the level of assistance needed for activities of daily living (ADLs) such as dressing, toileting, bed mobility, and transfers. The resident in question was an older male with moderate cognitive impairment, multiple complex medical diagnoses, and a history of falls. He was dependent on staff for most ADLs, including toileting, showering, and dressing, and was at risk for pressure injuries. Despite these needs being identified in his admission MDS assessment, the corresponding ADL care plan was not completed or available in the electronic medical record at the time of review. This omission was confirmed during interviews with the MDS Coordinator, who acknowledged the absence of the care plan and the potential for safety issues as a result. Further interviews with facility staff, including the Administrator and Director of Rehabilitation, revealed a lack of awareness regarding the missing care plan and inconsistencies in communication and responsibility for care plan development. The facility's own policy requires that care plans be individualized, comprehensive, and updated as resident conditions change, but this process was not followed for the resident, resulting in incomplete guidance for staff on how to meet the resident's needs.