Failure to Develop Comprehensive Care Plans for Residents With Malnutrition and ESRD
Penalty
Summary
Surveyors found that the facility failed to develop comprehensive, resident-centered care plans addressing all identified needs for two residents. One resident’s face sheet documented a diagnosis of severe calorie protein malnutrition, but the resident’s care plan dated 10/30/24 did not include any care plan addressing nutritional status or needs. Another resident’s face sheet documented a diagnosis of end stage renal disease (ESRD), and the resident stated he receives dialysis; however, the care plan dated 11/11/25 did not include any care plan related to ESRD or the required hemodialysis. The facility’s own Comprehensive Care Plan Policy, revised 6/25/25, states that an individualized comprehensive care plan with measurable objectives and timetables is to be developed for each resident to meet medical, nursing, mental, and psychological needs within seven days of completion of the comprehensive assessment (MDS). Despite this policy, the care plans for these two residents did not address their documented diagnoses and associated care needs.
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