Failure to Develop Comprehensive Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, resulting in unmet individualized needs. For one resident with severe cognitive impairment and multiple diagnoses, including dementia and psychosis, staff observed and reported consistent refusal and fear when being turned and repositioned. Despite these observations and reports to nursing staff, there was no care plan developed to address the resident's non-compliance with turning and repositioning, nor were interventions created to manage the resident's fear and refusal. For another resident with severe cognitive impairment and a diagnosis of PTSD, the facility did not create a care plan to address the PTSD diagnosis. The Director of Staff Development was unaware of the PTSD diagnosis, and there was no individualized, person-centered care plan in place to guide staff in managing the resident's mental health needs, triggers, or appropriate communication techniques. The absence of a care plan meant that staff were not aligned in their approach to care for this resident, and strategies for managing PTSD-related behaviors were not documented or implemented. The facility's policies and procedures require the development of comprehensive, person-centered care plans that address all identified medical, nursing, mental, and psychosocial needs, including trauma-informed care for residents with a history of trauma. In both cases, the facility did not follow its own policies, resulting in a lack of documented, measurable objectives and interventions for the residents' specific needs.