Failure to Develop Person-Centered Care Plan with Measurable Goals
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was reviewed for care planning. The resident had intact cognition and required moderate assistance with activities of daily living (ADLs). Diagnoses included acute respiratory failure with hypoxia, atrial fibrillation, hypertension, benign prostatic hyperplasia, diabetes mellitus, hyperkalemia, depression, obstructive sleep apnea, and mild cognitive impairment. The care plan for this resident included several problem statements such as ADL self-care performance deficit, diabetes management, altered cardiovascular and hematological status, use of antidepressant medication, pain management, vulnerability, altered respiratory status, and a wish to return to the community. However, each of these care plan entries lacked specific goals and interventions. During interviews, the DON and RN clinical coordinators confirmed that the MDS coordinator, who was responsible for entering and revising care plans, had left the facility several months prior, and the resident's care plan was neither completed nor individualized. The facility's policy required the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident, but this was not done for the resident in question.