Failure to Complete Comprehensive Care Plan Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, person-centered care plan within 7 days of completion of the comprehensive MDS assessment for one resident. Record review showed this resident was an adult male admitted with spastic quadriplegic cerebral palsy, spina bifida, recurrent depressive disorders, and protein-calorie malnutrition. His comprehensive MDS, identified as a nursing home comprehensive assessment with PASARR positive and a BIMS score of 11 (moderately cognitively impaired), had been completed, but the corresponding comprehensive care plan was not developed within the required 7-day timeframe as specified in the facility’s Comprehensive Care Planning policy dated March 2022. In interviews, the MDS nurse stated she was responsible for completing care plans after MDS assessments and acknowledged knowing the 7-day requirement. She explained that a new company had taken over the facility and the healthcare software had been changed, requiring her to manually enter each resident’s care plan into the new system, and she had not yet completed this resident’s care plan. The administrator confirmed that the MDS nurse was responsible for both the assessment and the comprehensive care plan and acknowledged awareness of the 7-day requirement, attributing the delay to the transition to the new company and software. The ADON also stated that the MDS nurse was solely responsible for completing care plans after assessments and reported that staff were relying on verbal reports to provide care when a care plan was not completed.
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