Failure to Develop Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive care plan for a resident with multiple complex medical conditions. The resident had diagnoses including a displaced fracture of the right femur, malignant neoplasm of the mouth and mandible, a laceration on the right forearm, and spinal stenosis. The Minimum Data Set (MDS) and Care Area Assessments (CAAs) triggered several areas requiring care planning, such as cognitive loss/dementia, functional abilities, urinary incontinence, psychosocial well-being, falls, nutritional status, pain, and dental care. Despite these identified needs, the comprehensive care plan did not address cognitive loss/dementia, psychosocial well-being, nutritional status, or dental care within the required timeframe after admission. Observations and record reviews showed that the resident required significant assistance with activities of daily living, had impaired mobility, was at risk for falls, experienced pain, and had a history of recent falls with injury. The resident also had a mechanically altered diet due to jaw cancer, experienced pain with swallowing, and was at risk for social isolation and depression. Staff interviews revealed confusion regarding responsibility for the care plan process, especially following recent staff changes. The MDS coordinator and administrative nurse acknowledged that the comprehensive MDS with triggered CAAs should have been incorporated into the care plan, but this was not completed as required. Additionally, the facility was unable to provide a comprehensive care plan policy when requested. Documentation indicated that while some aspects of the resident's care were addressed, key areas identified by the CAAs were omitted from the care plan. This failure to develop and implement a complete care plan placed the resident at risk for unmet care needs.