Failure to Develop Comprehensive Care Plan for Resident with Multiple Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple medical needs, as identified during the admission assessment and confirmed by staff interviews and record review. The resident had diagnoses including diabetes and a seizure disorder, with additional impairments such as limited range of motion in all extremities, use of a walker, and total dependence on staff for several activities of daily living. The Minimum Data Set (MDS) assessment and Care Area Assessments (CAAs) triggered several areas requiring care plan interventions, including communication, functional abilities, urinary incontinence, nutritional status, dehydration/fluid maintenance, dental care, and pressure ulcer/injury prevention. Despite these identified needs, the resident's current care plan did not address or include these areas of focus. Interviews with the MDS Coordinator confirmed that the comprehensive care plan was incomplete and that the areas triggered by the CAAs should have been included. The MDS Coordinator acknowledged that the care plan was not finished by the required deadline. The Administrator and DON also confirmed that a comprehensive care plan was expected to be developed in a timely manner, but this was not done for the resident in question.