Failure to Develop Comprehensive Care Plan for High-Risk Resident
Penalty
Summary
Surveyors identified that the facility failed to develop a comprehensive care plan for a resident with multiple medical conditions, including irritable bowel syndrome, hypertension, chronic respiratory failure, and urinary retention. The resident’s admission MDS documented a BIMS score of 14, indicating intact cognition, and showed that she was dependent on staff for toileting, dressing, and transfers, and had experienced one non-injury fall. A Falls Care Area Assessment dated 12/18/25 triggered due to impaired balance with transitions and transfers and the resident’s need for assistance with ADLs. The CAA identified contributing factors such as restricted mobility, medication use, need for assistance with transfers, and the presence of a urinary catheter, and listed risk factors including falls, injuries from falls, pain, and skin breakdown. The CAA stated that a care plan would be reviewed to assist in preventing falls and injuries related to falls. Despite these identified needs and risks, the resident’s care plan contained only one Focus related to activities, initiated on 12/08/25, with interventions limited to assisting the resident to and from activities and educating her daily about available activities. The care plan lacked additional Focus areas, goals, or interventions addressing the resident’s fall risk, impaired balance, dependence in ADLs, catheter care, or other clinical needs. During interviews, nursing staff, including a licensed nurse and administrative nurses, stated that the comprehensive care plan was expected to be completed within 21 days of admission, and one administrative nurse acknowledged she had not realized the resident’s comprehensive care plan had not been developed after the resident moved from the skilled unit to the long-term care side. The facility’s policy on Care Plan Revisions described a care planning process that should include assessment, goal setting, interventions, referrals, evaluation, and revision of care, which was not carried out for this resident.
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