Failure to Develop and Implement Comprehensive ADL Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple complex medical conditions, including hypertension, a history of stroke, tracheostomy, and gastrostomy status. The resident's medical record and assessments indicated a need for partial to moderate assistance with activities of daily living (ADLs) such as toileting, bathing, and personal hygiene, as well as decreased functional abilities due to impaired strength and mobility. However, the care plan only included directions for medication administration and communication during care, lacking specific staff instructions for ADL care and functional assistance. Interviews with staff revealed that certified nurse aides did not have access to the care plan and relied on nurses to communicate any special instructions. Administrative staff reported that interventions following incidents such as falls were discussed in meetings and added to the care plan, but there was no evidence that comprehensive, measurable objectives and time frames for ADL support were included for this resident. The facility's policy required individualized, person-centered care plans with measurable objectives and time frames, but this was not followed for the resident in question.