Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed the full scope of residents' medical, physical, mental, and psychosocial needs for several residents. For one resident with major depressive disorder, generalized anxiety disorder, and persistent mood disorder, the care plan did not include focused goals or interventions related to these diagnoses, despite documentation and staff awareness of the conditions and ongoing treatment. Interviews confirmed that staff expected these diagnoses to be reflected in the care plan, but they were not. Another resident with a diagnosis of Type 2 Diabetes Mellitus and specific physician orders for insulin administration did not have a care plan that addressed diabetes management, goals, or interventions. Staff interviews revealed that the diagnosis was missed in the care planning process, and the care plan did not reflect the resident's active medical needs. Additionally, a resident with limited English proficiency who primarily spoke Spanish did not have care plan documentation for communication needs or interpreter services, despite staff routinely using Spanish or translation devices to communicate with the resident. Further deficiencies were noted for a resident who exhibited behaviors such as cleaning the unit and collecting trash, which were not addressed in the care plan, even though staff recognized these as the resident's preferences and provided redirection for safety. Another resident with repeated episodes of intoxication and alcohol use outside the facility had no care plan focus or interventions related to these behaviors, despite multiple documented incidents and staff awareness. The facility's policy required comprehensive assessments and care plans based on residents' needs, but these requirements were not met for the residents reviewed.