Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident following her readmission after hip surgery. The care plan did not include critical physician orders such as hip precautions, toe-touch weight bearing status, or documentation of her Full Code advanced directive status. The resident's medical record indicated multiple complex diagnoses, including aftercare following joint replacement surgery, chronic pain, muscle weakness, and COPD, and she required substantial assistance with activities of daily living. Despite these needs, the care plan lacked individualized interventions and measurable objectives related to her current clinical status. Observations and interviews revealed that the resident was alert, oriented, and able to communicate her needs, including pain management. She reported not being involved in a care plan meeting with staff. The care plan on file focused primarily on social and cognitive engagement, with interventions such as encouraging family involvement and providing activity calendars, but omitted essential clinical care instructions and did not address her advanced directives or recent surgical aftercare requirements. Hospital discharge paperwork and physician orders for weight bearing and code status were present in the record but not incorporated into the care plan. Staff interviews confirmed that the care plan was incomplete and that responsibility for updating it fell to the MDS coordinators, both of whom were unavailable at the time. The part-time MDS coordinator and the ADON acknowledged that the care plan should have included hip precautions, pain management, and advanced directives. The CNO and Director of Social Services also recognized the omission, noting that the care plan was not updated after the resident's readmission and that this oversight resulted in the absence of necessary care information for staff.