Failure to Accurately Develop and Implement Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that accurately reflected the needs and circumstances of a resident. Specifically, the care plan for one resident indicated placement in a secured care unit due to a diagnosis of dementia and risk for elopement, despite the facility not having a secured unit. This discrepancy was identified through record reviews and staff interviews, which confirmed that no secured unit existed in the facility and that no residents required such placement at the time. Interviews with the Regional Nurse and the DON revealed a lack of awareness regarding the inaccurate care plan documentation. The DON acknowledged responsibility for ensuring care plans were correct but admitted she had not reviewed care plans for references to a secured unit, as the facility did not have one. The facility's policy requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes, but this was not followed in this instance.