Failure to Develop Comprehensive, Person-Centered Care Plan for Resident with Osteopenia
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident diagnosed with osteopenia, as well as other conditions including fracture, contracture, and disorders of bone density and structure in the right shoulder. The resident was totally dependent on staff for all activities of daily living and did not have the capacity to make decisions, according to the History and Physical. However, the Minimum Data Set indicated the resident was able to understand and be understood by others. The care plan in place for osteopenia included general interventions such as handling the resident gently and observing for joint pain and stiffness, but it did not specify the location of the osteopenia or provide detailed, measurable objectives and timetables tailored to the resident's specific needs. During an interview, the DON acknowledged that the care plan lacked specificity regarding the location of the osteopenia and stated that care plans are intended to guide resident care and should be more individualized. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables to address each resident's physical, psychosocial, and functional needs, but this was not implemented for the resident in question.