Failure to Complete Required Care Area Assessment Analyses
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) analysis for several residents within the required time frame, as identified through observation, record review, and interviews. Specifically, the CAAs for multiple care areas such as Functional Abilities, Nutritional Status, Falls, Urinary Incontinence and Indwelling Catheter, Psychotropic Drug Use, Cognitive Loss/Dementia, Psychosocial Well-Being, Mood State, Behavioral Symptoms, Activities, Communication, Delirium, and Pressure Ulcer were either missing or lacked proper analysis. In several instances, the documentation only stated 'will continue to monitor' (wctm) instead of providing a comprehensive analysis of the triggered care areas. This was observed in the records of four residents, where the required CAA analysis was not completed as per facility policy and regulatory requirements. Interviews with facility staff confirmed that the MDS assessments were completed off-site by regional staff, and that all triggered CAAs should include a complete analysis with measurable goals to inform the resident's person-centered care plan. The facility's policy emphasized that the Care Area Assessment Summary is essential for developing individualized care plans and that all Care Area Triggers must be addressed. The lack of proper CAA analysis placed residents at risk for unidentified care needs, as the assessments did not adequately address underlying causes, risk factors, or other contributing factors for the identified care areas.