Failure to Develop Comprehensive Care Plans for Specialized Treatments and Discharge Goals
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive care plans addressing specific clinical needs and discharge goals for three residents. One resident was admitted with necrotizing fasciitis, soft tissue disorders, rectal hemorrhage, and had both a colostomy bag and an indwelling urinary catheter. Physician orders directed staff to check the catheter strap and monitor urinary output every shift, and to check, empty, and replace the colostomy bag as needed. The admission MDS documented that the resident was cognitively intact and had both an indwelling catheter and an ostomy bag, and the CAA summary showed that urinary incontinence and indwelling catheter triggered a care area to be addressed in the care plan. Despite this, the comprehensive care plan dated after admission contained no care plan for colostomy care or indwelling urinary catheter care, and the DON and Administrator acknowledged these areas should have been included but could not explain the omission. Another resident with end stage renal disease had physician orders for dialysis, including monitoring the AV shunt every shift for thrill, bruit, and signs of bleeding, and scheduled dialysis at a kidney center three times weekly. The admission MDS indicated the resident was cognitively intact and received dialysis treatment, and the resident confirmed in interview that he had been receiving dialysis three times a week since admission. However, the comprehensive care plan last reviewed in early October contained no goals or interventions related to dialysis treatment. The DON stated that the MDS nurse was responsible for developing care plans and that a dialysis care plan should have been added, describing the absence of such a plan as an oversight, and the Administrator agreed that a dialysis care plan should have been developed. A third resident, admitted with metabolic encephalopathy, had an admission MDS showing moderate cognitive impairment and participation in discharge planning with a goal to return to the community. A social work progress note documented that the social worker and the resident’s emergency contact discussed seeking placement at an assisted living facility. The resident reported requesting assistance from the social worker and his emergency contact for placement in an assisted living facility or return home. Despite this documented discharge goal and discussions, the comprehensive care plan contained no interventions or goals related to discharge planning. The social worker, identified as responsible for discharge planning and related care plans, acknowledged awareness of the resident’s discharge wishes and support from the emergency contact but stated she did not know why a discharge focus area was not included and characterized it as an oversight; the DON and Administrator also stated that a discharge care plan should have been added.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.