Failure to Develop Comprehensive Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident diagnosed with dementia. According to the facility's own policy, each resident should have a care plan that includes measurable objectives and timetables to address their medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. However, a review of the resident's clinical record and care plan revealed that there were no documented goals or interventions specifically addressing the resident's dementia. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan for the resident was incomplete and did not address the resident's care needs related to dementia. The lack of a comprehensive care plan for this resident was identified through a review of facility policy, clinical records, and staff interviews.
Plan Of Correction
R57 care plan was updated to reflect the diagnosis of dementia with appropriate interventions. All residents with dementia were audited to ensure it was reflected appropriately in their care plans. NHA or designee will educate the RNAC department on the need for a dementia diagnosis to be care planned and reviewed with each MDS assessment to ensure care plans are person-centered. RNAC or designee will audit care plans for dementia diagnoses weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at QAPI and revised as needed.