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 three residents, resulting in unmet needs and increased risks. For one resident with an ileostomy, the care plan did not address her preference to maintain the stoma uncovered and self-manage care using personal washcloths, despite her cognitive intactness and repeated communication of her preferences to staff. Observations and interviews confirmed that staff were aware of her choices and the challenges with the ileostomy bag, but no individualized care plan was created to guide staff in honoring her preferences or managing associated risks. Another resident, who was cognitively intact and had a history of epilepsy, atrial fibrillation, and hypertension, repeatedly refused critical medications for seizure control and blood pressure management. The care plan did not address this ongoing medication refusal, and there was no documentation of person-centered interventions, education provided, or consistent notification of the responsible party and physician as required by facility policy. Staff interviews confirmed the absence of a care plan for medication refusal, and the responsible party reported not being informed of changes in the resident's condition. A third resident, with moderate cognitive impairment and a history of diabetes, depression, and gait abnormalities, exhibited self-harm behaviors by picking at wounds, leading to unhealed and bleeding injuries. No individualized care plan was developed to address this behavior or provide interventions for wound care. Additionally, the resident, identified as high risk for falls, did not receive consistent implementation of a toileting schedule or adequate supervision, resulting in an unwitnessed fall. Staff interviews and record reviews confirmed the lack of care planning and monitoring for both self-harm and fall prevention, despite documented high fall risk and previous incidents.