Failure to Develop Person-Centered Care Plan for Resident’s Visual Impairment
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan to address a resident's visual impairment, as required by its own policy and regulatory standards. The facility's policy on comprehensive person-centered care plans, dated December 2016, states that an interdisciplinary team, in conjunction with the resident and/or representative, must develop and implement a comprehensive person-centered care plan with measurable goals and timetables to meet the resident's physical, psychological, and functional needs. The policy further requires that areas of concern identified during the resident assessment be evaluated before interventions are added to the care plan, that the comprehensive care plan be developed within seven days of completion of the comprehensive MDS assessment, and that the care plan be reviewed and updated at least quarterly with the required quarterly MDS. Review of the clinical record for Resident R77 showed admission with diagnoses including Type 2 diabetes mellitus and dry eye syndrome of bilateral lacrimal glands. The resident's MDS assessment documented that the resident was visually impaired in Section B1000 (Vision) and cognitively intact with a BIMS score of 15 in Section C0500. Despite this documented visual impairment, there was no care plan developed to address the resident's visual impairment in the clinical record. In an interview, the resident stated that he cannot see. This lack of a care plan for the identified visual impairment constituted noncompliance with the facility's care plan policy and 28 Pa. Code 211.11(a) regarding resident care plans.
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