Failure to Develop Comprehensive, Timely Care Plan for Resident Needs
Penalty
Summary
The facility failed to develop and revise a comprehensive, person-centered care plan in a timely manner for a resident, as required by its policy and as stated by the MDS nurse. The resident was admitted with diagnoses including type 2 diabetes, chronic pain, anxiety disorder, muscle weakness, and bilateral age-related nuclear cataracts, and a quarterly MDS showed impaired cognition, need for substantial assistance with bed mobility and transfers, use of an electric wheelchair, and frequent bowel and bladder incontinence. On admission, the facility created care plans only for malnutrition and activities, and later, on a subsequent date, added care plans for diabetes mellitus, polypharmacy, hypertension, use of antidepressant, and activities of daily living. However, there were no care plans addressing transfers via mechanical lift, the resident’s verbal aggression toward staff and peers, or incontinence of bowel and bladder, despite these being identified needs. The DON confirmed the absence of these care plans, and the deficiency was identified incidentally during a complaint investigation. The facility’s own undated policy on comprehensive person-centered care plans required the interdisciplinary team, in conjunction with the resident and family, to develop and implement a comprehensive care plan for each resident, but this was not fully carried out for this resident, as evidenced by the missing care plan components for key clinical and behavioral issues.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.