Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in deficiencies related to the documentation and communication of their care needs and preferences. For one resident with severe cognitive impairment and multiple diagnoses, the care plan did not reflect the use of psychotropic medication (Depakote) or the resident's dependence on staff for activities of daily living (ADLs), despite physician orders and staff interviews confirming these needs. The Director of Nursing and MDS Coordinator acknowledged that these aspects should have been included in the care plan to ensure staff awareness and appropriate interventions. Another resident, who was cognitively intact and required substantial assistance with ADLs, had a care plan that failed to specify the type of assistance needed or her preference for bed baths. Interviews with the resident and staff confirmed that bed baths were provided according to her preference, but this was not documented in the care plan. The care plan only included a general intervention to assist with ADLs as needed, lacking the specificity required for person-centered care. A third resident, who had quadriplegia and moderately impaired cognition, preferred to be fed and assisted with ADLs by a family member who was also a resident. Although staff and the residents themselves confirmed this preference, the care plan did not address it. The MDS Coordinator, Activity Director, and other staff agreed that this preference should have been documented to ensure all staff were aware and could honor it. The facility's policy required individualized, person-centered care plans based on resident assessments, but this was not consistently implemented for these residents.