F0656

E

Non-measurable care plan goals for multiple residents

Brownwood, Texas Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for all five residents reviewed. The facility’s own policy required comprehensive care plans with measurable objectives and timeframes to address each resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. However, record review showed that multiple care plan goals were written in vague terms that could not be evaluated, quantified, or verified, such as residents remaining free of complications or adverse effects "through the review date" without specific, measurable criteria.

For one male resident with metabolic encephalopathy, essential hypertension, coronary artery disease, and cervical intervertebral disc stenosis, the care plan objectives for hypertension, adverse medication effects, altered cardiac problems, and intervertebral disc disorder/stenosis were not measurable. The goals stated that the resident would remain free of complications related to hypertension, free from adverse medication effects, free from signs and symptoms of cardiac complications, and free from pain or at an acceptable level of discomfort through the next review date, but did not include measurable parameters or timeframes that would allow staff to evaluate progress. Similar issues were found for another male resident with dementia, atrial fibrillation, bradycardia, anxiety disorder, seizure disorder, hypertension, and COPD, whose care plan goals for anticoagulant therapy, seizure disorder, hypertension, diuretic therapy, impaired visual function, hearing deficit, and use of antidepressant and anti-anxiety medications were all written in non-measurable terms such as remaining free from discomfort, adverse reactions, or complications.

A third male resident with acute kidney failure, unspecified dementia, vertebral fracture, hypertension, renal insufficiency, and glaucoma had care plan goals for hypertension, hypothyroidism, history of CVA, antiplatelet medication, advanced stage Alzheimer’s dementia, and impaired visual function that were similarly non-measurable. These goals included remaining free of complications related to hypertension/hyperlipidemia, being free from signs and symptoms of hypothyroidism, being free from complications related to a history of CVA, being free from discomfort or adverse reactions related to antiplatelet use, having needs anticipated and met with dignity maintained, and having no indications of acute eye problems, all without specific measurable criteria. A female resident with COPD, cognitive communication deficit, depression, hypertension, mild cognitive impairment, and chronic obstructive pulmonary disease had care plan goals for anticoagulant therapy, hypertension, diuretic therapy, impaired thought processes, and impaired vision that also lacked measurable objectives, using general statements about being free from complications or maintaining current function.

Another female resident with a displaced glenoid cavity fracture, type 2 diabetes, mild cognitive impairment, atrial fibrillation, hypertension, and diabetes mellitus had care plan goals for diabetes mellitus type 2, edema, adverse medication effects, hypertension, impaired visual function, hearing deficit, urinary retention related to an indwelling Foley catheter, and use of antidepressant medication that were not measurable. These goals included having no complications related to diabetes, fluid balance improving or not worsening, remaining free from adverse medication effects, remaining free of complications related to hypertension, having no indications of acute eye problems, maintaining the highest level of communication, remaining free from catheter-related trauma, and being free from discomfort or adverse reactions related to antidepressant use, again without quantifiable criteria. During interviews, both MDS coordinators acknowledged that the goals in the care plans were not measurable, with one stating she knew the goals were not measurable and that she and the other coordinator were working to develop measurable goals. The DON stated the IDT was responsible for creating measurable outcomes and agreed the outcomes needed to be measurable, and the Administrator also agreed the goals were not measurable and described the issue as a pattern.