Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans with measurable objectives and timetables for three residents, as required by regulation. For each of these residents, the electronic medical records contained blank care plans with no focus areas, goals, or interventions documented to guide direct care staff. The residents involved had complex medical histories, including conditions such as chronic obstructive pulmonary disease, hypertension, heart failure, Parkinson's disease, visual impairment, anxiety, depression, dementia, peripheral neuropathy, and osteoarthritis. Their Minimum Data Set (MDS) assessments indicated varying levels of cognitive function and assistance needs, but these assessments were not translated into individualized care plans. Interviews with facility staff, including the DON, ADON, and RDO, revealed that the MDS coordinator did not enter the care plans into the electronic medical record system, and that the process for developing care plans from MDS-triggered areas was not completed for the affected residents. Staff acknowledged that the responsibility for care plans lay with the DON and MDS nurse, and that there had been turnover in the MDS nurse position. The facility's policy required comprehensive, person-centered care plans to be developed within seven days of the required assessment and updated as resident conditions changed, but this was not followed for the residents in question.