Failure to Develop Comprehensive Person-Centered Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive, person-centered care plan for a male resident with multiple complex medical conditions, including autistic disorder, hypertension, urinary retention with an indwelling catheter, a history of urinary tract infections, and diabetes mellitus type II. The resident's admission Minimum Data Set (MDS) indicated severe cognitive impairment, short-term and long-term memory problems, and the need for special treatments such as oxygen therapy and anticoagulant medication. Despite these needs, the care plan initiated for the resident only addressed dietary needs and did not include plans for catheter care, diabetes management, oxygen therapy, anticoagulant use, or hypertension. Record reviews showed that the resident was prescribed multiple medications for hypertension, anticoagulation, and urinary retention, and had specific orders for catheter care and oxygen therapy. However, these critical aspects of care were not reflected in the resident's comprehensive care plan. Interviews with facility staff, including the DON, Interim Administrator, and MDS nurse, revealed a lack of clarity and follow-through regarding the timely completion of comprehensive care plans. The MDS nurse acknowledged that the comprehensive care plan for this resident was not completed after the assessment, stating it "fell through the cracks." The facility's own policy requires that a comprehensive, person-centered care plan be developed within seven days of the required MDS assessment and no more than 21 days after admission, including measurable objectives and timeframes for all identified needs. In this case, the policy was not followed, resulting in the resident not having a care plan that addressed all of his medical, nursing, and psychosocial needs.