Failure to Develop Comprehensive Care Plan for Resident with Multiple Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple complex medical conditions, including chronic pain, diabetes mellitus, depression, anxiety, muscle weakness, respiratory failure, and vision difficulties. Despite documentation in the resident's electronic medical record and Minimum Data Set (MDS) assessments indicating the need for assistance with activities of daily living (ADLs), toileting, bed mobility, and bathing, the care plan lacked direction for several critical areas such as medication administration, risk of dehydration, falls, pressure ulcers, psychosocial well-being, ADLs, activities, vision difficulties, and bowel and bladder function. The Care Area Assessments (CAAs) identified these needs and recommended follow-up or monitoring, but these were not translated into specific, measurable care plan interventions. Staff interviews confirmed that all nursing staff had access to the resident's care plan and Kardex, and that the director of nursing was responsible for ensuring the care plan was developed and updated. However, the care plan did not reflect the resident's individualized care needs as identified in the assessments and CAAs. The facility's policy required the development and implementation of a comprehensive, person-centered care plan with measurable objectives and time frames, but this was not followed for the resident in question.