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 two residents, as required by policy and regulatory standards. For the first resident, who had multiple complex diagnoses including respiratory failure, cerebral infarction, sepsis, metabolic encephalopathy, diabetes, hypertension, narcolepsy, congestive heart failure, and a right above-the-knee amputation, the care plan did not address all areas triggered by the comprehensive assessment. Specifically, the care plan omitted interventions for cognition, activities, communication, and returning to the community, despite these needs being identified in the resident's assessment. Similarly, the second resident, who had a history of anemia, neurogenic bladder, aphasia, Parkinson's disease, dehydration, hypokalemia, malnutrition, dysphagia, fracture, urinary tract infection, cognitive deficit, lack of coordination, muscle weakness, schizophrenia, and falls, also had an incomplete care plan. The care plan failed to address cognition, activities, and nutrition, even though these areas were triggered in the assessment. The Director of Nursing confirmed that the facility did not have an MDS Coordinator at the time, and that not all triggered areas were being captured in the care plans.