Incomplete and Inaccurate Care Plan Documentation
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident, as evidenced by a review of the resident's care plan documentation. Multiple focus areas within the care plan were found to be incomplete or lacking specific information. For example, the section addressing pain management did not specify the type of pain, its duration, or the resident's preferred method of pain control. Similarly, the focus area for bowel incontinence lacked any further details, and the section on communication problems was left blank, despite the resident not having any communication issues. The goals and interventions listed were generic and did not include individualized or measurable actions. Additionally, the care plan's section on assistance with activities of daily living (ADLs) was incomplete, only listing possible levels of assistance without specifying the resident's actual needs. The deficiencies were confirmed by a corporate RN, who acknowledged that the care plan was both incomplete and contained incorrect information regarding the resident's communication abilities. These findings were based on record review, staff interview, and resident interview during the survey process.