Failure to Complete Comprehensive Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days after the completion of the comprehensive assessment for one resident. Record review showed that the resident, an older male with multiple diagnoses including anxiety disorder, atrial fibrillation, heart failure, diabetes, and asthma, was admitted with several medications and required continuous oxygen. The resident was also developing a pressure ulcer. While a baseline care plan was completed upon admission, there was no evidence of a comprehensive care plan being completed within the required timeframe after the comprehensive assessment. Interviews with facility staff revealed that the MDS Coordinator was responsible for completing the comprehensive care plan but had overlooked this task for the resident in question. The MDS Coordinator acknowledged the omission and described the process typically used to complete care plans, including the use of CAAs, physician notes, and orders. Other staff, including the LVN and DON, confirmed that the comprehensive care plan had not been completed as required and recognized that this failure could impede the resident's treatment. Facility policy requires that a person-centered care plan be developed within seven days after the comprehensive assessment.