Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by regulatory standards. For one resident admitted with multiple diagnoses including urinary tract infection, sepsis, diabetes, chronic kidney disease, hypertension, and myocardial infarction, the admission MDS assessment triggered several care areas such as ADL functional/rehabilitation potential, urinary incontinence, nutritional status, dehydration/fluid maintenance, and pressure ulcer. However, the resident's care plan did not address any of these areas and was only focused on activities. The comprehensive care plan was completed late, beyond the required timeframe, and did not include the necessary care areas as identified by the MDS assessment. Another resident, with a history of hemiplegia, chronic heart failure, schizoaffective disorder, and acute respiratory failure, was found to be using smokeless tobacco in their room. The quarterly MDS assessment indicated moderate cognitive impairment, but the comprehensive care plan did not include any focus area for the use of smokeless tobacco. Staff, including the RN and DON, were unaware of the resident's tobacco use, and the omission was attributed to a possible oversight during a recent discharge and readmission. Facility policy requires that care plans incorporate identified problem areas and associated risk factors, which was not followed in this case. A third resident, diagnosed with Alzheimer's disease and chronic kidney disease, had a severely impaired cognition score on the admission MDS. The care plan for this resident only addressed participation in group activities and code status, omitting all other care areas triggered by the MDS, such as dental, discharge plans, diet, medication, specialized equipment, behaviors, or ADLs. Both the MDS nurse and DON confirmed that the comprehensive care plan was incomplete and not updated within the required timeframe after the resident's return from the hospital, as mandated by facility policy.