Failure to Develop Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident with multiple complex medical needs. The resident was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and a urinary tract infection. Upon admission, the resident was noted to have severely impaired cognition, a Stage 4 pressure ulcer on the sacrum, and a deep tissue injury (DTI) on the right heel. The resident also had an indwelling urinary catheter and significant hearing difficulties, having recently lost his hearing aids. Despite these documented needs, a review of the resident's care plans from admission through several weeks later revealed that there were no care plans addressing the resident's hearing impairment, wounds, or indwelling catheter. Interviews with facility staff, including the Assistant Administrator, Licensed Vocational Nurse, Medical Records Assistant, and Director of Nursing, confirmed that these critical areas were not included in the resident's care planning documentation. Staff acknowledged that care plans should have been developed for these issues and that various team members, such as the MDS coordinator, treatment nurse, or Social Services Director, could have initiated them. The facility's own policy requires the development and implementation of a person-centered comprehensive care plan to address each resident's medical, physical, mental, and psychosocial needs. However, in this case, the absence of care plans for the resident's hearing loss, wounds, and indwelling catheter represented a failure to follow this policy, potentially impacting the delivery of appropriate care and services.