Failure to Develop Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed all identified needs for three residents, as determined through clinical record review and staff interviews. For one resident with diabetes, lower limb cellulitis, and gastro-esophageal reflux disease, the Minimum Data Set (MDS) Care Area Assessment (CAA) summary indicated that vision, activities of daily living, dental care, and nutrition should be addressed, but there was no documented evidence that interventions for these areas were included in the care plan. Another resident with hearing loss, high cholesterol, and a recent total knee replacement had communication, nutrition, and activities of daily living identified as care areas in the MDS CAA summary, yet these were not reflected in the care plan documentation. A third resident with a diagnosis of depression was noted in the MDS CAA summary to require care plan interventions for psychotropic drug use. Review of the medication administration record showed the resident received an antidepressant over several months, but there was no documentation of interventions related to psychotropic drug use in the care plan. The Director of Nursing confirmed during interviews that the identified care areas were not addressed in the care plans for these residents.