F0656

D

Failure to Develop Comprehensive ADL Care Plan for a Resident

Dallas, Texas Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for activities of daily living (ADLs) for one resident. Record review showed this male resident, with diagnoses including UTI, anxiety disorder, bipolar disorder, schizophrenia, and depression, had an MDS assessment indicating intact cognition (BIMS score of 15) and a need for supervision or touching assistance with personal hygiene tasks such as combing hair, shaving, and washing/drying face and hands. However, review of the resident’s care plan, last reviewed on 02/11/26, revealed no plan of care addressing ADLs with measurable objectives, goals, interventions, and timeframes, despite the facility’s written policy requiring a comprehensive person-centered care plan to meet medical, nursing, mental, and psychosocial needs.

During interviews, the DON stated that every resident should have a care plan reflecting their likes, dislikes, everyday routine, and anything that affected them, and acknowledged that the absence of ADLs in the care plan diminished staff communication and knowledge of resident preferences. The DON explained that the MDS Coordinator was responsible for updating residents’ care plans, but the facility did not have an MDS Coordinator nurse and instead used a corporate person for MDS assessments, while the DON handled acute and new resident care plans. The Administrator similarly stated that the care plan told a story about the resident’s care and preferences and confirmed that without ADLs listed, staff would not know what residents liked. The Administrator indicated that charge nurses were responsible for triggering acute care plans and the MDS Coordinator for updating care plans, but again noted the absence of an MDS Coordinator.