Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for three residents, as evidenced by medical record reviews and staff interviews. One resident, who required assistance with activities of daily living (ADLs) as documented in the Minimum Data Set (MDS), did not have these needs addressed in their care plan. The Director of Nursing (DON) confirmed that the care plan was not comprehensive and did not capture the resident's ADL needs. Another resident, admitted for therapy and with a goal of discharge to an assisted living facility (ALF), had a care plan that only included staff discussing discharge needs with the family. There was no documentation in the care plan regarding assistance with identifying an appropriate ALF placement or obtaining necessary supplies and services for discharge, despite the responsible party's stated goals and the social worker's reported practices. A third resident, who was occasionally incontinent of urine according to the admission MDS assessment, had triggered a care area assessment (CAA) for urinary incontinence, with a decision to address this in a care plan. However, review of the care plans revealed that urinary incontinence was not addressed. The DON confirmed that the care plan did not include interventions for urinary incontinence, despite the CAA indicating it should be addressed. These findings demonstrate that the facility did not consistently develop or implement care plans that addressed all identified resident needs.