Failure to Develop Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop an individualized, person-centered comprehensive care plan for a resident with multiple complex medical needs, including end stage renal disease, encephalopathy, and diabetes. The resident required supervision to total assistance with activities of daily living (ADLs), was receiving dialysis three times a week, and had physician orders for insulin administration before meals and at bedtime. Despite these needs being identified in the Minimum Data Set (MDS) and Care Area Assessment (CAA), a review of the resident's electronic medical record and care plan revealed that there were no care plan interventions in place for insulin use, behaviors, dialysis, or ADL functioning as of the review date. Interviews with facility staff indicated that the initial baseline care plan was completed by staff nurses, while the comprehensive care plan was the responsibility of the MDS nurses. Due to a transition in MDS nursing staff, the comprehensive care plan for this resident was overlooked and not completed within the required timeframe. Both the MDS nurse and the Director of Nursing acknowledged that the comprehensive care plan should have addressed all of the resident's needs and been completed appropriately.