Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple complex medical conditions, including unspecified dementia, cerebral infarction, aphasia, and atrioventricular block. Despite the resident's significant cognitive and functional impairments, including severely impaired decision-making skills, memory problems, and dependence on staff for daily activities such as oral hygiene, toileting, showering, and personal hygiene, there was no care plan available in either the electronic or paper chart. Staff interviews revealed confusion and lack of clarity regarding responsibility for care plan development and updates, particularly following the absence of an MDS nurse. The social worker, ADON, and DON all indicated uncertainty about whether a care plan had ever been completed for the resident, and after an extensive search, no documentation of a care plan or care plan meeting could be found. Facility policy requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, based on thorough assessment. However, in this case, the required care plan was not present, and staff were unable to confirm its existence or completion. This deficiency was identified through interviews and record reviews, which confirmed the absence of the care plan and highlighted gaps in the facility's processes for ensuring timely and consistent care planning for residents with complex needs.