Failure to Address Cognitive Impairment in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan addressing a resident's cognitive communication deficit. The resident was admitted with multiple diagnoses, including malignant neoplasm of the mandible, temporomandibular joint disorder, and severe protein-calorie deficit. Hospital records and a speech therapy evaluation documented the resident's cognitive impairment and the presence of a guardian or public fiduciary. Progress notes and the Minimum Data Set (MDS) assessment further indicated cognitive and communication difficulties, but the MDS lacked a Brief Interview for Mental Status (BIMS) score and omitted staff assessment for mental status. Although a communication care plan was initiated, it only addressed the resident's jaw carcinoma and related communication challenges, without incorporating interventions for the cognitive impairment. There was no evidence in the care plan or clinical record that the resident's cognitive deficits were specifically addressed or that interventions were implemented to mitigate associated risks. This omission was contrary to facility policy, which requires comprehensive, person-centered care plans with measurable objectives and timetables based on ongoing assessments. The lack of appropriate care planning for cognitive impairment was highlighted by two incidents where the resident was found outside the facility, having become confused and lost while ambulating. Staff interviews confirmed the importance of care planning for known deficits and the potential for negative outcomes when such plans are not in place. Facility policies also emphasized the need for behavioral assessment and immediate safety strategies for residents with impaired cognition, which were not reflected in the resident's care plan.