Failure to Document Resident Functional Abilities in Care Plan
Penalty
Summary
Facility staff failed to develop an accurate, person-centered comprehensive care plan for one resident. The resident was admitted with multiple diagnoses, including unsteadiness on feet, a healing femur fracture, a history of falls, abnormal gait and mobility, and a need for assistance with personal care. The resident's Minimum Data Set (MDS) assessment documented specific levels of assistance required for various activities of daily living (ADLs), such as eating, oral hygiene, toileting, bathing, dressing, transfers, and mobility. However, review of the resident's care plan revealed that staff did not document the resident's functional level or the assistance needed to complete ADLs. During interviews, the DON confirmed that the care plan did not include the resident's functional abilities and expressed uncertainty about whether this information should be included. The corporate nurse subsequently confirmed that care plans should include residents' functional abilities. The lack of documentation in the care plan could result in staff being unaware of the resident's current and actual needs.