Failure to Develop Comprehensive Care Plan for Resident with Legal Blindness
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed all of a resident's needs, specifically omitting care plans for activities of daily living (ADL) and legal blindness. The resident in question was admitted with multiple diagnoses, including acute respiratory failure with hypoxia, second-degree burns, legal blindness, and a history of homelessness. Despite being assessed as alert and oriented with a BIMS score of 15 out of 15, the resident's care plan only included interventions for skin issues, discharge planning, and fall risk, with no mention of ADL support or accommodations for legal blindness. Review of the facility's policy indicated that care plans should describe services to help residents attain or maintain their highest practicable well-being. However, documentation in the electronic medical record and interviews with the MDS Coordinator confirmed that the required care plans for ADL and legal blindness were not developed or entered. The MDS Coordinator acknowledged the omission and stated that staff were responsible for completing care plans, but could not explain why the comprehensive care plan was incomplete.