Failure to Include Dementia Diagnosis in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all of a resident's needs, specifically omitting the diagnosis of dementia from the care plan for one resident. Record reviews showed that the resident had a documented diagnosis of unspecified dementia, which was listed as a secondary admission diagnosis and was also identified as an active diagnosis in the Minimum Data Set (MDS) assessment. The MDS assessment further revealed a severely impaired cognition score and triggered the need for care planning related to cognitive loss/dementia. Despite these findings, the resident's care plan did not include any focus or interventions related to dementia. Interviews with facility staff, including the ADON, MDS coordinator, and DON, confirmed that the responsibility for updating and reviewing care plans was shared among them. All acknowledged that the resident's dementia diagnosis should have been included in the care plan, as required by facility policy and the MDS triggers. The facility's policy mandates that all identified needs from the comprehensive assessment, including those triggered by the MDS, must be addressed in the care plan with measurable objectives and timeframes. The omission was attributed to a failure in the process of updating and reviewing the care plan, as confirmed by staff interviews and record reviews.