Failure to Develop and Implement Comprehensive Person-Centered Care Plan for Medically Complex Resident
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple complex medical conditions. The resident, an older adult male with intact cognition (BIMS score of 14), had active diagnoses including coronary artery disease, end-stage renal disease, heart failure, hypertension, diabetes mellitus, peripheral vascular disease, GERD, pneumonia, COPD, hyperlipidemia, depression, PTSD, anemia, and pain. His face sheet, MDS, and MAR confirmed these active conditions and corresponding medications, yet review of his comprehensive care plan initiated in early March showed no care plans addressing any of these active complex medical conditions. During interviews, the resident reported dissatisfaction with nursing care, stating that staff were not doing their job properly, that medications were sometimes not given on time, and that he and his family were looking for another facility. He also reported a missing watch that he suspected was taken by staff. The MDS coordinator stated he was responsible for initiating, updating, and completing care plans, received information on residents’ conditions during daily IDT meetings, and believed he had completed the resident’s care plan after the MDS assessment in early February, but the record review showed otherwise. Additional staff interviews revealed that nurses were not using or relying on care plans in practice. One RN working PRN stated she used the Kardex for resident care, had never referred to care plans, and was unaware of their relevance, noting she had never received in-service training on care plans. Another RN reported she did not rely on care plans, instead using the 24-hour report and other assessment tools, and stated she was unfamiliar with person-centered care plans or how to implement interventions listed in them, instead basing daily care on IDT meeting notes. An LVN stated she had worked with the resident and had not noticed the absence of care plans for his conditions, acknowledged that care plans are important for goals and interventions, and reported she had never received in-services on care plans. The DON and ADM both stated that care plans are essential and integral to nursing care, and the facility’s written policy required a comprehensive, culturally competent, trauma-informed person-centered care plan with measurable objectives and timetables for each resident’s medical, nursing, mental, and psychosocial needs, which was not in place for this resident.
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