Failure to Address Identified Care Needs in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with diagnoses including dementia, major depressive disorder, and chronic kidney disease, the clinical record and Minimum Data Set (MDS) assessment indicated severely impaired cognition, impaired communication, frequent urinary incontinence, and a need for substantial assistance with toileting hygiene. The MDS Care Area Assessment (CAA) summary specified that communication and urinary incontinence should be addressed in the care plan, but there was no documented evidence that interventions for these areas were included. For another resident with a history of cerebral infarction, hemiplegia, hemiparesis, and urinary tract infection, the MDS and CAA summary identified urinary incontinence as a care area to be addressed, yet the care plan lacked documented interventions for this need. The Nursing Center Operations Manager confirmed during an interview that the identified care areas were not addressed in the care plans for these residents.