Failure to Maintain Comprehensive Person-Centered Care Plan After Admission
Penalty
Summary
Surveyors identified that the facility failed to develop an individualized, person-centered comprehensive care plan for one resident. The resident was admitted with dementia, Parkinson's disease, DM, hypertension, and arthritis, and the admission MDS showed moderately impaired cognition, need for supervision or assistance with eating, bed mobility, oral hygiene, toileting, transfers, bathing, and dressing, as well as bowel and bladder incontinence. The MDS also documented that the resident was on a therapeutic diet, at risk for pressure ulcer development with no current wounds, had no pain or weight loss, had received antipsychotic, antianxiety, and hypoglycemic medications, and was planning to discharge back to the community. Review of the resident’s comprehensive care plan showed only one entry, developed by the RD, addressing potential nutritional problems, with no other care areas included despite multiple triggered CAAs. The CAAs completed by the MDS Coordinator identified needs in cognitive loss/dementia, functional abilities for self-care and mobility, urinary incontinence, psychosocial well-being, activities, falls, nutritional status, pressure ulcer injury, and psychotropic drug use, but these were not reflected in the written care plan. During interview, the MDS Coordinator confirmed that the only care plan entry present was for nutrition, stated she remembered completing the comprehensive care plan, and acknowledged awareness that a comprehensive care plan must be developed within 21 days of admission. She reported that there had been two recent computer upgrades and thought something may have happened to the resident’s care plan during those updates. The Administrator stated she expected all residents to have an accurate and complete comprehensive care plan reflecting their clinical condition, medications, and care needs.
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