Failure to Develop Care Plan for Visual Impairment
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan that included specific and individualized interventions to address the visual impairment needs of a resident. Review of the facility's policy indicated that care plans should include measurable objectives and time frames to meet all identified needs. However, for a resident admitted with diagnoses including hip fracture, depression, migraine, and documented as legally blind, the care plan did not address the resident's visual impairment. The resident's MDS assessment showed highly impaired vision, and a progress note confirmed legal blindness with a need for staff assistance in keeping belongings within reach. Despite these documented needs, the resident's care plan lacked any interventions or objectives related to visual impairment. This omission was confirmed during interviews with an LPN, the DON, and the Nursing Home Administrator, all of whom acknowledged the absence of a care plan addressing the resident's visual impairment. The deficiency was identified through review of policies, clinical records, observations, and staff interviews.