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, resulting in unmet needs and inadequate care. For one resident with a left heel blister, the care plan was not updated in a timely manner to reflect the progression to a suspected deep tissue injury (SDTI). Although clinical documentation and wound care consults identified the need for specific interventions such as offloading the heel and using specialized mattresses, these interventions were not incorporated into the care plan until several days after the wound was reclassified. Interviews with nursing staff and the DON confirmed that the care plan update and implementation of person-centered interventions were delayed, despite the recognized importance of immediate action for wound healing and prevention of further decline. Another resident experienced a prolonged period of not being weighed, with no weight recorded for five months. The care plan only generically noted the resident's preference not to be weighed, without documenting the underlying reason or providing interventions to address the refusal. Interviews and observations revealed that the resident's refusal was due to pain caused by the lift equipment used for weighing, not a lack of willingness. The facility did not assess or accommodate this need, nor did they document efforts to resolve the issue. When the resident was finally weighed with proper support, a significant weight loss was discovered, which had gone unmonitored due to the lack of a comprehensive and individualized care plan. A third resident's care plan was not adequately personalized upon admission or when new skin issues developed. The resident, who had multiple risk factors including cognitive impairment and immobility, developed a right buttock pressure injury that progressed from redness to an unstageable wound and eventually to a stage four pressure injury. The care plan did not reflect timely updates or specific interventions in response to changes in the resident's condition. Staff interviews indicated that risk assessments were not reassessed when the resident's condition changed, and necessary interventions such as increased repositioning and nutritional support were not promptly implemented or documented in the care plan.