Incomplete Care Area Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete Care Area Assessments (CAAs) that addressed the individual underlying causes, contributing factors, and risk factors for five residents. For these residents, the CAAs triggered by the Minimum Data Set (MDS) assessments, such as those related to psychotropic drug use, dental care, behavioral symptoms, and cognitive loss/dementia, lacked required analysis of findings. The documentation did not include an analysis of the residents' conditions or the factors contributing to their care needs, as required by facility policy and federal guidelines. Staff interviews revealed that the MDS nurse responsible for completing the CAAs was not adequately educated on how to complete the CAA notes, resulting in incomplete documentation. Administrative staff confirmed that the CAAs were not completed as they should have been and lacked necessary analysis and risk findings. The facility's policy required that each triggered CAA be fully assessed and documented, but this was not done for the identified residents, placing them at risk for inadequate care due to unidentified care needs.