Failure to Develop Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, resident-centered care plans were developed and implemented for two residents. For one resident with dementia, heart failure, and muscle weakness, the care plan did not include directions for managing daily wandering behavior, despite documentation in the MDS assessment and multiple observations of the resident wandering into other residents' rooms and approaching exit doors. The Director of Nursing confirmed that the care plan should have addressed the resident's wandering. For another resident with Parkinson's disease and dysphagia, the care plan did not document the resident's significant difficulty with speech (dysarthria) or the use of a communication board, even though physician notes and communication records indicated these needs. Staff were instructed to encourage the resident to speak slower and use the communication board, but these interventions were not reflected in the care plan. The Director of Nursing acknowledged the omission upon review.