Failure to Develop Care Plan for Cognition in Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing cognition for a resident with severe cognitive impairment. The resident had diagnoses of Parkinson's Disease and panic disorder, and a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Despite this, a review of the resident's admission record and care plan revealed that no care plan had been created to address the resident's cognitive needs. During an interview and record review, the DON confirmed that a care plan should have been developed for the resident's cognitive impairment, but none was present. The facility's policy requires the interdisciplinary team to create and implement a comprehensive care plan with measurable objectives and timeframes for each resident, including those with cognitive issues. This process was not followed for the resident in question.