Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents. For Resident #1, a female with essential primary hypertension admitted in late February and discharged in early March 2026, record review showed an admission MDS with a BIMS score of 09 (moderately impaired cognition), completed on 03/04/2026. However, review of the care plan tab on 03/18/2026 revealed there was no comprehensive care plan in the record. The facility’s policy required that the IDT, with the resident and/or representative, develop a comprehensive care plan within seven days of completion of the required MDS assessment. For Resident #2, a male with a diagnosis of encounter for surgical aftercare following circulatory system surgery and an original admission in mid-February with a readmission in early March 2026, review of the care plan tab on 03/19/2026 also showed no comprehensive care plan. His BIMS evaluation showed a score of 15, indicating intact cognition. In interviews, the MDS nurse stated that if there was no care plan under the care plan tab, one had never been opened or created, and reported she had mentioned in morning meeting that care plans for these residents needed to be opened because she could not open them herself. She explained that only one RN besides the DON could open or create a care plan and that she typically followed a three-day rule after admission to have comprehensive care plans opened. The DON stated that any IDT member could initiate or create a care plan but it was closed by the DON or another RN, and while he was able to locate baseline care plans for both residents, he could not find their comprehensive care plans and was unsure why they were not completed, acknowledging that responsibility for verifying completion rested with him.
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