Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including metastatic cancer, COPD, chronic pain, depression, and cognitive impairment. Despite the resident's admission assessment and physician orders indicating needs related to pain management, code status, ADL functional status, incontinence, cognitive loss, skin risk, diet, and psychotropic drug use, the care plan only addressed fall risk and functional discharge goals. No other focus areas or interventions were documented in the comprehensive care plan, leaving significant aspects of the resident's care unaddressed. Observations, interviews, and record reviews revealed that the care plan was not completed in a timely manner and did not reflect the resident's current needs as identified in the comprehensive assessment. The new DON, who had just assumed the role and was still being trained on care plan procedures, confirmed that the previous DON was responsible for care plans and acknowledged the importance of having a complete care plan to manage the resident's care. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed for the resident in question.