Failure to Complete Comprehensive Care Plan Following Quarterly MDS
Penalty
Summary
The facility failed to develop and complete a comprehensive, person-centered care plan within 7 days of the comprehensive assessment for one resident, as required by facility policy. Record review showed that the resident, an adult male with multiple complex medical 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, had a quarterly MDS assessment completed on 02/05/26 with a BIMS score of 14, indicating intact cognition. Despite this, the only care plan in place as of 03/05/26 addressed the resident’s noncompliance with facility smoking policies, and there were no care plans addressing his medical, nursing, mental health, or other psychosocial needs. During interviews, the resident reported dissatisfaction with nursing care, stating that staff were not doing their jobs properly, that medications were sometimes not given on time, and that a personal item (a watch) had gone missing, which he suspected was taken by staff. The MDSC, who worked remotely and was responsible for initiating, updating, and completing care plans, stated he believed he had completed the care plan within the required 7-day timeframe and acknowledged that care plans are integral to nursing care and must be timely. The DON, who was new to the facility, stated she was unaware that there was no proper care plan for the resident based on the quarterly MDS and agreed that the missing care plan related to the resident’s medical conditions was a concern. The ADM stated that the resident had prior care plans before a period out of the facility and that the MDSC failed to transfer and update those care plans after the recent quarterly MDS, suggesting a possible system glitch, and confirmed that the resident’s conditions were not reflected in the current care plan.
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.