Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans that addressed all identified needs for several residents. For multiple residents with complex medical and behavioral histories, care plans did not reflect current physician orders, observed behaviors, or required monitoring. For example, one resident with dementia and behavioral issues was being monitored for paranoia, hallucinations, delusions, and verbal aggression, but these behaviors were not included in her care plan. Another resident with depression and chronic pain was monitored for increased sadness, excessive sleeping, and overeating, yet these behaviors and specific side effects to monitor for her antidepressant were not documented in her care plan. Additional deficiencies were noted for residents with psychiatric and neurological conditions. One resident with aphasia and on psychotropic medication was monitored for behaviors such as being snappy, short-tempered, and experiencing air hunger, but these were not included in her care plan, nor was there documentation to monitor for adverse side effects of her medication. Another resident with bipolar disorder, anxiety, and depression did not have these diagnoses or related interventions and triggers documented in her care plan, despite being a trauma survivor. The facility also failed to address physical safety and equipment use in care plans. A resident with a history of falls and a recent fall incident did not have fall prevention interventions documented or updated in the care plan following the event. Another resident who used bed rails daily did not have this use reflected in her care plan. Staff interviews confirmed that these omissions were recognized and acknowledged as deficiencies in the care planning process.