Failure to Develop Person-Centered Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans for two residents who were reviewed for care planning. For one resident, the admission Minimum Data Set (MDS) assessment indicated multiple complex medical conditions, including atrial fibrillation, heart failure, hypertension, peripheral vascular disease, renal insufficiency, diabetes, anxiety, and schizophrenia, as well as a history of falls and frequent incontinence. Although several care areas were triggered by the MDS and documented as addressed, the resident's record lacked a comprehensive, person-centered care plan. The temporary care plan provided to nursing assistants only included basic information such as diagnoses, diet, and assistance needs, but did not constitute a full care plan as required. For the second resident, the admission MDS assessment also identified significant functional impairments, including the need for assistance with eating, oral hygiene, toileting, dressing, and mobility, as well as frequent bowel incontinence and the presence of an indwelling catheter. Multiple care areas were triggered, but the only care plan item documented was a potential nutritional deficit, with no comprehensive care plan completed at the time of the survey. Interviews with staff confirmed that comprehensive care plans had not been developed for either resident, despite facility policy requiring such plans to be completed within 21 days of admission.