Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident during their 35-day stay. Despite the resident having multiple medical diagnoses, including hypertension, diabetes, seizure disorder, bacterial infection, and anxiety, and requiring several medications and interventions, no comprehensive care plan was created or maintained during their admission. The Minimum Data Set (MDS) assessment identified several care areas that required attention, such as ADL function, urinary incontinence, nutritional status, and pressure ulcer risk, but these were not addressed in a formal care plan. Interviews with facility staff confirmed that the comprehensive care plan was not completed or entered into the system while the resident was present. The MDS nurse acknowledged responsibility for care plan entry and stated that the plan was typically completed within 14 days, but admitted that it was not done for this resident. The DON and other staff also confirmed that care plans are expected for all residents and are monitored by multiple team members, but in this case, no care plan was in place. No facility policy for care plans was provided during the survey.