Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, resulting in disorganized documentation and the omission of critical interventions. For two residents with multiple medical conditions and cognitive impairments, the care plans listed all medical problems together without grouping them by specific issues, and the associated goals and interventions were not tailored to individual problems. Instead, interventions were mixed together, making it difficult for staff to identify which actions corresponded to which medical issues. Both nursing and administrative staff acknowledged that this disorganization could lead to delays in care and miscommunication among healthcare providers. In another instance, a resident who expressed a desire to smoke was assessed by the interdisciplinary team and determined to require the use of a smoking apron for safety. However, the resident's care plan did not include the intervention of wearing the apron, despite this being identified as necessary in the assessment. Staff interviews confirmed that the omission was an oversight, and that the care plan is the primary tool used to communicate required interventions to all staff. The absence of this intervention in the care plan created the potential for staff to allow the resident to smoke without the required safety equipment. The facility's own policies and procedures require that care plans be comprehensive, coordinated, and based on individual assessments, including specific goals, interventions, and review dates. In each of the cases reviewed, the care plans did not meet these requirements, as they failed to clearly communicate individualized problems and interventions, and in one case, omitted a critical safety intervention altogether.