Failure to Develop Comprehensive Care Plan After Admission
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 one resident following their admission. Record review showed that the resident was admitted with diagnoses including heart failure, Parkinson's disease, and respiratory failure. The Minimum Data Set (MDS) 5-day admission assessment was completed and signed by the MDS RN, but a review of the electronic medical record for the resident's stay did not reveal a comprehensive care plan. Only an initial care plan and some additions were found, but no complete comprehensive care plan was documented. The interim Director of Nursing confirmed that, despite reviewing the care plan and electronic medical record, a comprehensive care plan had not been completed for the resident.