Failure to Develop Comprehensive Care Plan for Resident with Multiple Needs
Penalty
Summary
A deficiency was identified when a facility failed to develop and implement a comprehensive care plan for a resident with multiple medical conditions, including diabetes, heart failure, and dementia. The resident was admitted on July 15, 2025, and the Minimum Data Set assessment and Care Area Assessment summary dated July 21, 2025, indicated that the resident's urinary incontinence, dental care, self-care and mobility, and pressure ulcer required care plan interventions. However, a review of the clinical record revealed that there was no evidence these care areas were addressed in the resident's care plan. During an interview, the Director of Nursing confirmed that there was no documented evidence that the identified care areas were included in the care plan for this resident. This lack of documentation and failure to address the resident's assessed needs in the care plan constituted noncompliance with the requirement to develop and implement a comprehensive, person-centered care plan based on the resident's comprehensive assessment.
Plan Of Correction
NotSpecified Resident 18 was updated to accurately reflect the goals of admission, preference for and potential for future discharge, discharge plan, and services provided in the facility. Resident's updated care plan included interventions for the following: to address Resident 18's urinary incontinence, dental care, self-care, mobility, and pressure ulcer. All residents have the potential of being affected by the deficient practice. All other residents were audited to ensure that the care plans are comprehensive and reflective of the goals of admission, preferences for and potential for future discharge, as well as discharge plans. Comprehensive care plans will be reviewed within days of the resident's RAI assessment. All pertinent disciplines will be educated on the policies and procedures that reflect care plans which are reflective of the goals of admission, potential for future discharge, and the discharge plans. An audit will be completed by the DON/Designee once a week for at least 3 residents for 6 weeks to ensure an accurate plan of care for residents that is reflective of the goals of admission, preferences/potential of discharge, and discharge plans. All findings will be reported and reviewed by the QAPI committee monthly. Date of Compliance: 08/26/2025