Failure to Address Resident Preferences and Dental Needs in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for three residents. For one resident, the care plan did not include their stated preferences for music, pets, and religious activities, despite these being documented in the Minimum Data Set (MDS) and confirmed by the Activity Director. Similarly, another resident's care plan omitted their preferences for religious/spiritual activities, music/radio, and did not mention the provision of a monthly activity calendar, even though these preferences were documented in their activity evaluation and confirmed as missing by the Activity Director. Additionally, a third resident with a dental issue was not care planned for dental status, despite having a dentist's recommendation for extraction of remaining maxillary teeth and documentation in the MDS Care Area Assessment (CAA) process indicating the need for dental care interventions. The resident reported needing a tooth extraction and experiencing pain, but the care plan only addressed routine oral care and did not include a focus on dental issues. The Assistant Director of Nursing confirmed the absence of dental care planning for this resident.