Failure to Develop Comprehensive, Resident-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for one resident with significant care needs. The resident had multiple diagnoses, including a disorder of bone density, contractures at multiple sites, functional quadriplegia, and respiratory failure. Documentation showed the resident was totally dependent on staff for activities of daily living (ADLs) such as showering, dressing, oral hygiene, and personal hygiene, and lacked the capacity to understand or make decisions. Despite these needs, the care plan interventions were generic and did not specify critical details, such as the requirement for two-person assistance during care, nor did they provide measurable objectives or timetables tailored to the resident's condition. During interviews and record reviews, the DON acknowledged that the care plan was not person-centered and did not ensure the resident's needs were being met. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not reflected in the resident's care plan. The lack of specificity and individualized planning placed the resident at risk for injuries and unmet needs.