Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and implement accurate, comprehensive care plans for all residents, as evidenced by two specific cases. In the first case, a resident admitted with multiple diagnoses including vascular dementia, type II diabetes mellitus, major depressive disorder, Alzheimer's disease, cerebral atherosclerosis, and a history of mini stroke did not have a comprehensive care plan completed within the required timeframe. The resident's electronic medical record showed no documentation of a completed care plan following admission, despite facility policy and staff interviews confirming that such a plan should have been developed within 21 days. In the second case, another resident with diagnoses including paranoid schizophrenia, congestive heart failure, major depressive disorder, morbid obesity, type II diabetes mellitus, mild intellectual disabilities, impulse disorder, COPD, and high blood pressure exhibited repeated behavioral incidents involving theft of food and beverages from other residents. These behaviors were documented in multiple incident reports and ultimately led to the resident being moved to a locked memory care unit. However, the resident's care plan was not updated to address these behaviors or the move, contrary to facility policy and staff expectations that care plans should be updated promptly when such behaviors occur or when a resident is transferred to a different unit. Interviews with facility staff, including the Social Services Director, MDS Coordinator, Administrator, and DON, confirmed that comprehensive care plans should be completed and updated in a timely manner to reflect residents' needs and changes in condition or behavior. The failure to complete and update care plans as required resulted in deficiencies in meeting the comprehensive care planning requirements for these residents.