Failure to Develop Comprehensive Care Plan for Resident with Cardiac and Mental Health Diagnoses
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with myocardial infarction and major depression. The resident's electronic medical record indicated a history of heart attack and persistent mood disorder, with an admission MDS showing intact cognition and documented behaviors such as rejection of care. Despite being independent in all activities of daily living, the resident's EMR did not contain a comprehensive care plan as required. Facility policy mandates an individualized, person-centered interdisciplinary plan of care for all residents, but this was not completed in a timely manner for the resident in question, as confirmed by administrative staff.