Failure to Complete Comprehensive Care Plan After Assessment
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days of completing a comprehensive assessment for one resident. The resident was admitted with multiple diagnoses, including a left humerus fracture, history of falls, and urinary tract infection. The admission MDS assessment indicated significant care needs, such as upper extremity impairment, partial to moderate assistance with ADLs, frequent incontinence, risk for pressure ulcers, and a history of falls. The Care Area Assessment (CAA) identified several triggered care areas, including ADL function, urinary incontinence, falls, pressure ulcers, and nutrition, with care plan decisions completed for these areas. However, a review of the resident's medical record showed that the care plan only addressed discharge planning, mood disorder, and activities, and did not include focus areas or interventions for the triggered care areas identified in the CAA. Interviews with the MDS Coordinator and the Administrator confirmed that the comprehensive care plan had not been completed as required, and the omission was acknowledged as an oversight by the responsible staff.