Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident who was admitted with multiple medical conditions, including multiple pelvic fractures, glaucoma, and anxiety. The resident was found to be cognitively intact upon admission, and the Care Area Assessment (CAA) Summary identified eight areas of concern that required care planning: Visual Function, Activities of Daily Living Function, Urinary Incontinence, Falls, Dental Care, Pressure Ulcer, Psychotropic Drug Use, and Pain. However, only four care plans were present in the resident's record, covering Social Services discharge planning, Advanced Directives, Activities, and Nutritional Status. During interviews, the MDS nurse responsible for the resident's assessments and care plans admitted to forgetting to complete the required care plans, and the Director of Nursing confirmed that comprehensive care plans should be completed on time.