Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions. The care plan did not address several critical areas, including pain management, risk for pressure ulcer development, assistance needed for activities of daily living (ADLs), bowel and bladder incontinence, medications for disease management, hospice care, the reason for oxygen therapy, DNR status, fall risk, and elopement risk. Despite the resident's significant medical history—including COPD, diabetes, pneumonia, hypertension, bipolar disorder, depression, chronic kidney disease, benign prostatic hyperplasia, low back pain, jaw pain, age-related decline, and asthma—only two care areas were documented: pneumonia and a behavior problem related to smoking while on oxygen. Interviews and record reviews revealed that the resident was at high risk for falls and elopement, was on multiple medications for various conditions, and was receiving hospice care and oxygen therapy. The resident's MDS assessment indicated moderate cognitive impairment, frequent pain, and incontinence issues. Physician orders and clinical assessments further documented the need for comprehensive care planning in these areas. However, the care plan was not updated to reflect these needs, and essential interventions and goals were omitted. Staff interviews indicated a lack of clarity and follow-through regarding care plan responsibilities. The MDS nurse, DON, ADON, and social worker each described different understandings of who should update the care plan and when, with some staff stating they had never updated a care plan. The facility's policy required a comprehensive, person-centered care plan to be developed and updated as needed, but this was not followed in practice for this resident, resulting in a deficient practice that could impact the delivery of necessary care and services.