Failure to Develop and Implement Comprehensive Care Plan for Resident with Behavioral Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant behavioral and cognitive needs. Record reviews showed that the resident had diagnoses including dementia with psychotic disturbance, delusions, hallucinations, and depression, and was assessed with a BIMS score of 2, indicating severe cognitive impairment. The resident also exhibited behaviors such as wandering and rejection of care, as documented in the MDS. However, the care plan dated 4/16/2025 did not include any focus, goals, or interventions addressing these behaviors. Interviews with the DON and MDS coordinator confirmed that these behaviors should have been included in the care plan to ensure appropriate care and staff awareness. Both acknowledged that the omission was a failure to follow the facility's care planning policy, which requires the IDT to develop and implement a comprehensive, person-centered care plan describing the services needed to attain or maintain the resident's highest practicable well-being. The lack of a care plan for the resident's wandering and rejection of care was directly attributed to the MDS department not ensuring these needs were addressed.