Failure to Complete Comprehensive Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident within the required timeframe. Specifically, a female resident with diagnoses including Alzheimer's disease, dementia, aortic stenosis, and osteoporosis was admitted, and her records showed a severely impaired cognitive status with a BIMS score of 6. Despite these needs, a comprehensive care plan had not been completed within 21 days of admission, as required by both federal regulations and the facility's own policy. The MDS Coordinator confirmed that the comprehensive MDS assessment and subsequent care plan were not completed on time, attributing the delay to efforts to get caught up with new admissions. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that responsibility for care plan development was shared among the MDS Coordinator, DON, and ADON. The DON and other key staff were new to the facility and acknowledged they were still organizing processes and were unaware that the resident's care plan was overdue. Review of the facility's policy and the CMS RAI Manual confirmed the requirement for care plan completion within 21 days of admission, which was not met in this case.