Failure to Develop Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident with multiple complex medical conditions. The resident, a cognitively intact female with diagnoses including cancer, coronary artery disease, heart failure, hyperlipidemia, GERD, protein calorie malnutrition, anxiety disorder, and respiratory failure, was admitted and assessed as occasionally incontinent of bladder and continent of bowel. Her assessment triggered care areas such as incontinence, pressure sore, pain, falls, ADLs, and psychotropic medications. Despite these identified needs, the care plan did not address all triggered areas, specifically omitting the anti-anxiety medication Sertraline prescribed for anxiety. Interview with the MDS Coordinator confirmed that the care plan did not include the anti-anxiety medication and acknowledged the oversight, attributing it to challenges with a new program and the need to address all care areas promptly, especially for short-stay residents. Review of facility policy indicated that a comprehensive, person-centered care plan should be developed within seven days of the required MDS assessment, involving the interdisciplinary team and the resident or their representative. The failure to include all triggered care areas in the care plan was identified through record review and staff interview.