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, as identified through observations, interviews, and record reviews. For one resident with hemiplegia, diabetes, and anxiety disorder, the care plan did not address her use of a vape or smoking, despite documentation and staff acknowledgment that she engaged in these activities and required supervision when smoking. The MDS Coordinator confirmed awareness of the resident's smoking and vaping but stated these were not included in the care plan, which was acknowledged as an oversight. Another resident with schizoaffective disorder and mild intellectual disabilities, who was identified by the PASRR process as having serious mental illness and an intellectual disability, was receiving clozapine, an antipsychotic medication. The care plan for this resident did not specify the use of clozapine or include interventions related to its administration, nor did it address the resident's PASRR status. The DON confirmed that these aspects should have been included in the care plan and attributed the omission to a recent change in facility ownership. A third resident, diagnosed with vascular dementia, bipolar disorder, and mild cognitive impairment, resided in the memory care unit. The care plan for this resident addressed risks for wandering and elopement but did not mention the resident's placement in the memory care unit. The MDS Coordinator acknowledged that this information should have been included in the care plan and noted that recent organizational changes contributed to the oversight. Facility policy requires comprehensive, person-centered care plans to be developed and updated to reflect all identified needs and services, but this was not followed for these residents.