Failure to Develop Comprehensive Care Plan for Resident’s Hearing Loss
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, individualized care plan addressing a resident’s left ear hearing loss. The resident was admitted with diagnoses including epilepsy, a femur fracture, and end stage renal disease, and an MDS assessment dated 10/25/2025 documented that the resident had adequate hearing and cognitive skills for daily decision making, with varying levels of assistance needed for ADLs. An ENT consult dated 12/25/2025 documented a three-year history of hearing loss, wax removal, patient education, and a recommendation for follow-up in six months or more. Despite this documented history and evaluation, the resident’s medical record contained no care plan problem, goals, monitoring parameters, comfort measures, or physician notification requirements related to hearing loss. During an observation and interview, the resident, seated in bed, expressed concern about ongoing hearing loss in the left ear and reported having received treatment once at the facility, but questioned whether additional interventions would be offered since the hearing loss persisted and had begun prior to admission. The MDS nurse confirmed that a review of the record revealed no care plan, orders, or guidance to address the resident’s hearing loss, and stated that the resident should have a care plan for each current diagnosis and problem. The DON similarly stated that a comprehensive care plan should have been initiated for the resident’s hearing loss to guide nurses in monitoring for worsening hearing, communicating effectively with the resident, and notifying the provider if the problem worsened. The facility’s policy required the interdisciplinary team to develop an individualized comprehensive care plan for each identified problem area within seven days of completing the comprehensive MDS and to update it with significant changes or at least quarterly, which was not done for this resident’s hearing loss.
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