Failure to Develop Comprehensive Care Plan for Mask Non-Compliance During COVID-19
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan with measurable objectives for a resident who was non-compliant with wearing a face mask during a COVID-19 outbreak. The resident, who had diagnoses including Alzheimer's disease, generalized muscle weakness, and a cervical vertebra fracture, was assessed as having severely impaired cognitive skills and was dependent on staff for activities of daily living and mobility. Despite being exposed to COVID-19, the care plan only included general interventions such as educating the resident on hand hygiene, mask use, and social distancing, without addressing the resident's specific non-compliance behavior or providing measurable objectives and individualized interventions. Observations showed the resident repeatedly in the hallway without a face mask or with the mask improperly worn, interacting with others. Staff interviews confirmed that the resident required frequent and constant reminders to stay in her room or wear a mask, and that a care plan addressing her non-compliance was not created when the behavior was first noted. Facility policy required ongoing assessment and revision of care plans as resident conditions changed, but this was not followed in the case of this resident's non-compliance with infection control measures.