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 several residents, as identified through observations, interviews, and record reviews. For one resident receiving hospice services, the care plan did not include any focus area, goals, or interventions related to hospice care, despite orders indicating the resident was on hospice and staff acknowledging that such planning should be present. This omission meant that the resident's comfort and end-of-life needs were not addressed in the care plan. Another resident with a history of wandering and an order for a Wanderguard device did not have care plan interventions addressing the use or monitoring of the device, nor were there interventions for the resident's wandering tendencies. Documentation failed to reflect the presence or monitoring of the Wanderguard, and care plans for psychotropic medications lacked specificity regarding the medications, related diagnoses, and symptoms to monitor. Similarly, another resident with wandering behaviors did not have care planning related to wandering or increased observation, and their care plan also lacked specific details about medication management. For two residents with contractures, the facility failed to implement or identify appropriate care plan interventions. One resident had orders and therapy recommendations for a palm protector to prevent further contracture, but interviews revealed inconsistent application and lack of staff awareness regarding the intervention. The other resident had a contracture but no orders or restorative nursing program in place, and the care plan only included general interventions without specific devices or monitoring. These failures were contrary to facility policy and placed residents at risk of not receiving care and services related to their identified needs.