Failure to Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans for three residents within the required timeframe. Record reviews showed that for each of these residents, no care plan was implemented within 21 days of admission, despite multiple care areas being triggered by their admission MDS assessments. These care areas included cognitive loss/dementia, ADL function/rehab potential, urinary incontinence/indwelling catheter, psychological well-being, falls, nutritional status, pressure ulcer, pain, and other significant health concerns. The residents affected had complex medical histories, including conditions such as rheumatic mitral stenosis, bipolar disorder, chronic kidney disease, diabetes mellitus type 2, atrial fibrillation, fractured femur, hypertension, and obesity. Their assessments indicated varying levels of cognitive impairment and substantial assistance required for activities of daily living. Despite these needs, the electronic health record reviews confirmed that no individualized care plans were in place for these residents during the survey. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the care plans had not been completed as required. The MDS Coordinator was unable to explain why the previous MDS nurse had not completed the care plans, and both staff members acknowledged the importance of care plans in providing individualized care. Facility policy also required the development and implementation of comprehensive care plans to meet each resident's needs, but this was not followed for the residents in question.