Failure to Develop Comprehensive Care Plans for ADL and Elopement Risk
Penalty
Summary
The facility failed to develop comprehensive care plans to address the specific needs of two residents in the areas of activities of daily living (ADL) and elopement risk. For one resident with multiple complex diagnoses, including chronic obstructive pulmonary disease, heart failure, diabetes, schizophrenia, and morbid obesity, the quarterly Minimum Data Set (MDS) assessment indicated total dependence on staff for toileting, bathing, dressing, and personal hygiene. However, there was no care plan in place to address these ADL needs, a fact confirmed by both the Director of Nursing (DON) and a Registered Nurse (RN). In another case, a resident with a history of diabetes, schizophrenia, major depressive disorder, and partial blindness was identified as being at risk for elopement according to the facility's own risk assessment protocol. Despite this, the resident's care plan did not address elopement risk, even though the facility's policy required such planning for residents identified as at risk. This omission was also verified by the DON and RN during interviews.