Failure to Develop and Implement Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement individualized comprehensive care plans addressing specific identified needs for three residents. For one resident with intact cognition and multiple diagnoses including muscle wasting, diabetes, encephalopathy, schizoaffective disorder, and seizures, the facility investigated a facility-reported incident involving an allegation of misappropriation of money. The investigation indicated that a safe keeping of valuables care plan would be implemented, but review of the medical record showed that no such care plan was added. During interviews, facility leadership confirmed that the resident’s care plan did not address safe keeping of valuables and acknowledged that it should have been included. A second resident with end stage renal disease and intact cognition was identified on the MDS as receiving dialysis, yet the medical record contained no dialysis care plan, which was confirmed by the DON. A third resident with Alzheimer’s disease, anxiety, depression, and moderate cognitive impairment, and who had an activated POA for healthcare, was known by staff to have dementia-related behaviors such as sometimes refusing to get out of bed, requiring staff to reapproach later. However, review of this resident’s care plan showed no interventions for Alzheimer’s disease/dementia care. The DON verified that this resident did not have an Alzheimer’s disease/dementia care plan, despite facility policies requiring resident-centered care plans for individuals with dementia and comprehensive care plans describing services to maintain residents’ highest practicable well-being.
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