Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to follow and fully develop comprehensive, resident-centered care plans for three residents. For one resident with intact cognition and diagnoses including anxiety disorder, depression, neurocognitive disorder with Lewy bodies, and borderline personality disorder, the care plan included interventions such as behavioral health consults and weekly social service visits. However, documentation revealed that these weekly visits were not consistently documented, and the social services designee admitted to not recording refusals or all visits. The resident reported that visits were infrequent and often occurred incidentally during housekeeping, rather than as planned, sit-down visits. Staff observations confirmed the resident spent most of her time in bed with the lights off, and staff did not consistently invite her to participate in group activities as outlined in her care plan. For a second resident with severe cognitive impairment and a history of behavioral symptoms, the care plan included administration of antipsychotic and antidepressant medications but failed to specify target behaviors for these medications. Progress notes documented multiple incidents of sexual inappropriateness, combativeness, and disruptive behaviors, including inappropriate touching of staff, yelling, cursing, and physical aggression. Despite these documented behaviors, the care plan did not address or include interventions for these specific behaviors, nor did it provide guidance for staff on how to manage them. A third resident with severe cognitive impairment and diagnoses of chronic kidney disease, dementia, anxiety, depression, and insomnia was prescribed multiple psychotropic medications. The care plan referenced the use of these medications but did not include individualized target behaviors for staff to monitor or non-pharmacological interventions to attempt if behaviors were observed. Staff interviews confirmed that the care plan lacked this information, and the facility's policy required care plans to be individualized and comprehensive, incorporating behavioral and emotional health needs. The failure to individualize and fully implement care plans for these residents constituted the deficiency.