Failure to Develop Comprehensive, Person-Centered Care Plan for Medically Complex Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident with multiple complex medical conditions. The resident’s EMR documented diagnoses including suspected adrenal insufficiency, hypothyroidism, myxedema, and a prior cerebral infarction, with associated right-sided impairment, use of a walker, and need for supervision or touching assistance with care. The admission MDS and multiple Care Area Assessments (CAAs) identified issues in visual function, functional abilities (self-care and mobility), urinary incontinence/indwelling catheter, falls, nutritional status, pressure ulcer/injury, and psychotropic drug use, and each CAA stated these areas would be addressed in the care plan. Despite this, the resident’s care plan dated 08/12/25 only documented that the resident wished to stay in the facility and was a full code, and lacked any additional information or specific interventions related to the identified care areas. The resident had active physician orders for levothyroxine for myxedema, trazodone for insomnia, methadone for pain, and continuous oxygen at two liters, but these treatments and related care needs were not reflected in a comprehensive care plan. Staff interviews showed that a CMA stated staff should follow the care plan to care for residents, while an LN reported she did not enter information into the care plan. An administrative nurse explained that an offsite MDS nurse started the care plan and the interdisciplinary team was supposed to add to it as needed, but acknowledged the team had not kept up with updating the care plan. Another administrative nurse stated it was her expectation that care plans reflect the resident’s care and be started and updated as needed. These findings demonstrated that, contrary to the facility’s policy requiring a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, the resident’s care plan was incomplete and did not address the resident’s identified physical, psychosocial, and functional needs.
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