Failure to Develop Person-Centered Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who exhibited various challenging behaviors and refused medications. The resident, who had multiple diagnoses including morbid obesity, transient cerebral ischemic attack, hypertension, cognitive communication deficits, diabetes, and a urinary tract infection, was also being treated for anxiety, visual hallucinations, and disorientation. Despite these complex medical and psychological needs, the facility did not create a comprehensive care plan to address the resident's behaviors and medication refusals. The resident displayed a range of behaviors from January to March 2025, including kicking, scratching, yelling, screaming uncontrollably, refusing meals and medications, and exhibiting increased anxiety. The resident also attempted to climb out of bed, removed clothing, and was combative with staff. These behaviors were documented in nursing notes, which detailed incidents of the resident being anxious, confused, lethargic, and aggressive, often requiring staff intervention and, at times, hospitalization. Despite these documented behaviors, the facility did not have a plan of care in place to manage the resident's behaviors effectively. The Unit Manager confirmed the absence of a person-centered care plan to address and manage the resident's behaviors, which was a significant oversight given the resident's complex needs and the frequency of behavioral incidents. This lack of a comprehensive care plan was a deficiency in meeting the regulatory requirements for developing and implementing person-centered care plans.
Plan Of Correction
The facility does and shall develop and implement comprehensive person-centered care plans for each resident, that includes measurable objectives and timeframes also consistent with the residents' rights to meet resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The facility does and shall ensure that comprehensive care plan is culturally competent. All residents' comprehensive care plans will be reviewed to ensure they are comprehensive and include any interventions deemed necessary. All nursing staff have/will be educated on proper comprehensive care planning and the importance of ongoing care plan updates to ensure the most effective and contemporary care. Monitoring/random review of comprehensive care plans will be conducted 1 time weekly for 3 months with findings reported to the CQI Committee for a period deemed appropriate by the CQI Committee. Monitoring/random review of comprehensive care will be conducted 1 time weekly for 3 months with findings reported to the CQI Committee for a period deemed appropriate by the CQI Committee.