Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop person-centered, comprehensive care plans that accurately reflected the specific needs and preferences of four residents. For three residents with documented advance directives, the care plans did not specify the residents' chosen code status, despite this information being available in the medical record and flagged on the face sheet. For example, one resident was identified as Full Code in both the physician orders and face sheet, but the care plan only generically referenced code status without specifying Full Code. Another resident's care plan mentioned advanced directives but did not state the resident's DNR preference, and a third resident's care plan referenced comfort care and hospice services but omitted the code status preference, even though the face sheet indicated DNR. Additionally, for a resident on hospice with a history of stroke and pressure ulcers, the care plan referenced the use of a low air loss mattress but did not include an order or directive for the alternating pressure mattress that was in use. There was also no documentation available to staff regarding the appropriate settings for the air mattress, and the care plan did not reflect the actual equipment or its management. Interviews with staff revealed uncertainty about who was responsible for care plan completion and a lack of clarity regarding the documentation and communication of equipment settings.