Failure to Develop Comprehensive Care Plan for Resident’s Chronic Medical Conditions
Penalty
Summary
Surveyors identified that the facility failed to develop a person-centered comprehensive care plan with measurable objectives and timeframes for a cognitively intact resident with multiple active medical diagnoses. The resident, who has Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Anemia, Pyothorax without Fistula, Emphysema, Paranoid Personality Disorder, Pneumonia, and Paranoid Schizophrenia, had these conditions documented in the admission comprehensive assessment and active diagnoses section. Despite this, the resident’s admission and current care plans did not include the medical conditions of Anemia, Type 2 Diabetes Mellitus, Hypertension, and Hyperlipidemia, even though these needs were identified in the comprehensive assessment. Record review showed that the resident was receiving multiple physician-ordered medications related to these diagnoses, including Sodium Chloride for anemia, Carvedilol and PRN Hydralazine for hypertension, Metformin for Type 2 diabetes, and Atorvastatin for hyperlipidemia, all administered as prescribed over several months. During an interview, the MDS Coordinator acknowledged that the resident had these diagnoses and related medications, and confirmed that they were not reflected on the care plan. The MDS Coordinator stated that the resident should have a care plan so caregivers know the diagnoses and how to provide appropriate care. This omission occurred despite the facility’s written comprehensive care plan policy, which requires development and implementation of a person-centered care plan with measurable objectives and timeframes for all medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment.
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