Failure to Develop Comprehensive Care Plans for ADLs, Activities, and Discharge Goals
Penalty
Summary
Surveyors found that the facility failed to develop comprehensive care plans for activities of daily living (ADLs) and activities for one resident, and for discharge planning for another resident. One resident with neurocognitive disorder with Lewy bodies and muscle weakness had a significant change MDS assessment indicating cognitive impairment and dependence on staff for personal hygiene, bathing, and toileting, and that it was somewhat important to participate in group activities. However, review of the comprehensive care plan showed no care plan for ADLs or activities. The MDS Coordinator stated that the resident was dependent on staff for ADLs per the MDS but was not care planned because the care area did not trigger on the MDS. The Assistant Activities Director, who completed the significant change MDS and coded the resident as finding group activities somewhat important, acknowledged that she did not create an activities care plan because she had not yet been trained on how to complete a care plan and agreed one should have been developed. The Administrator confirmed that care plans for ADLs and activities should have been developed and was unsure why these areas were omitted. For another resident admitted with polyarthritis and metabolic encephalopathy who later discharged home, the admission MDS showed the resident was cognitively intact, participated in discharge planning, and had a goal to return to the community. Despite this, the comprehensive care plan contained no goals or interventions related to discharge planning. The Social Worker, who reported being responsible for discharge planning and related care plans, stated she was aware of the resident's goal to return to the community but had not developed a discharge care plan and characterized this as an oversight. The DON and Administrator both indicated that the Social Worker should have created a discharge care plan and also described the omission as an oversight.
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