Failure to Develop Comprehensive Care Plans for Residents with Dementia and Recurrent UTIs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two out of five residents reviewed. For one resident with severe cognitive impairment and a diagnosis of non-Alzheimer's dementia, the care plan did not include any focus area, goals, or interventions related to the dementia diagnosis, despite this being documented in the resident's Minimum Data Set (MDS). For another resident with a documented history of recurrent urinary tract infections (UTIs), the care plan similarly lacked any focus area, goals, or interventions addressing the UTI diagnosis, even though the resident had multiple recent episodes of UTIs treated with antibiotics and this condition was noted by the physician. Clinical record reviews, staff interviews, and policy review confirmed these omissions. The Director of Nursing acknowledged that care plans are expected to accurately reflect residents' health conditions, including specific diagnoses and related interventions. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timeframes for all identified needs, but this standard was not met for the residents in question.