Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific needs. For one resident with severe cognitive impairment and multiple physical dependencies, there were physician orders for bed and chair sensor alarms to alert staff when the resident attempted to get up unassisted. Despite these orders and the presence of the devices, the resident's care plan did not address the use, monitoring, or effectiveness of the sensor alarms. Both the MDS Coordinator and the Director of Nursing confirmed that the care plan lacked necessary interventions and guidance for staff regarding the alarms. Another resident, who was dependent on staff for most activities of daily living and had a history of cerebral infarction and muscle weakness, refused to get out of bed and participate in activities for three consecutive days. Although the care plan included interventions for pressure ulcer prevention that required the resident to get out of bed unless contraindicated, there was no care plan developed to address the resident's ongoing refusal to get out of bed. Staff interviews confirmed that refusals were reported to nursing staff and the physician, but the care plan was not updated to reflect this issue or guide staff response. The facility's policy requires the interdisciplinary team to develop a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes based on the resident's assessment. In both cases, the facility did not ensure that the care plans addressed all identified needs and physician orders, resulting in a lack of individualized interventions and measurable actions for the residents involved.