Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required. Specifically, one resident receiving hospice services did not have a care plan addressing hospice care, another resident with a seizure disorder did not have a care plan related to seizure management, and a third resident with a Do Not Resuscitate (DNR) order did not have a care plan reflecting their DNR status. These omissions were identified through interviews and record reviews, which showed that the care plans lacked measurable objectives and time frames to meet the residents' needs. For the resident on hospice, records indicated a diagnosis of cerebral infarction and severe cognitive impairment, with hospice services ordered and initiated, but no corresponding care plan entry. The resident with a seizure disorder had a diagnosis of metabolic encephalopathy and dementia, was receiving anticonvulsant medication, and had physician orders for seizure management, yet there was no care plan addressing this condition. The resident with a DNR order had multiple chronic conditions and a signed DNR form in the record, but the care plan did not reflect this advanced directive. Interviews with facility staff, including the LVN, DON, MDS Coordinator, and Administrator, revealed inconsistent understanding and implementation of care planning processes. Staff described various methods for verifying code status and updating care plans, but acknowledged gaps in ensuring that all relevant diagnoses and directives were consistently reflected in the care plans. The facility's care plan policy was requested but not provided to the survey team during the survey.