Failure to Develop and Implement Comprehensive, Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, as required. Specifically, the care plan did not include measurable objectives or time frames to address the resident's medical, nursing, mental, and psychosocial needs. The care plan noted that the resident was resistive to care but did not specify what types of care the resident resisted. Additionally, the care plan referenced the use of certain medication classes, such as opioids, diuretics, and anticoagulants, but did not list the specific medications being administered. Record reviews showed that the resident had a history of refusing medications and being weighed, as documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for two consecutive months. The resident had intact cognition and required varying levels of assistance with activities of daily living. The Minimum Data Set (MDS) indicated that the resident had refused evaluation or care, including bloodwork, medication, and ADL assistance, on multiple occasions. Interviews with MDS Coordinators revealed that care plans were often not updated with specific medication names due to frequent changes in prescriptions and the short-term nature of many residents' stays. The coordinators acknowledged that the care plan should have specified what the resident was resistant to and that incomplete care plans could affect staff knowledge and the delivery of appropriate care. The Director of Nursing confirmed that MDS Coordinators were responsible for ensuring the accuracy of comprehensive care plans and that updates were supposed to be made based on input from all departments.