Failure to Develop Comprehensive Care Plan for ADLs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for activities of daily living (ADLs) for a resident. Record review showed that the resident, a 90-year-old individual with multiple diagnoses including idiopathic peripheral autonomic neuropathy, depression, secondary hypertension, atrial fibrillation, and chronic diastolic congestive heart failure, required varying levels of assistance with ADLs such as toileting hygiene, bathing, dressing, eating, and oral hygiene. Despite these needs being identified in the most recent MDS assessment, the resident's care plan did not include a plan of care for ADLs, nor did it specify measurable goals, interventions, or timeframes related to these needs. Interviews with facility staff, including the Administrator, DON, and MDS Nurse, confirmed that the absence of ADLs in the care plan diminished staff communication and knowledge of the resident's preferences and routines. The staff acknowledged that the care plan should reflect the resident's functioning, preferences, and required assistance, and that the MDS Coordinator was responsible for updating the care plan. Review of the facility's care plan policy indicated that the interdisciplinary team is required to coordinate and review care plans based on assessments within specified timeframes, but this process was not followed for the resident in question.