Failure to Implement Person-Centered Care Plans for Two Residents
Penalty
Summary
The facility failed to implement person-centered care plans for two residents, resulting in deficiencies related to staff adherence to documented interventions. For one resident with a history of cerebral infarction and behavioral issues, the care plan required two staff members to be present for all care due to a history of sexually inappropriate and accusatory behaviors. Despite this, multiple CNAs reported providing care to the resident alone, and direct observation confirmed that care was delivered by a single staff member. The unit manager confirmed the ongoing need for two-person care, and the DON stated that staff should have access to and follow the care plan at all times. For another resident with moderate cognitive impairment and impaired vision, the care plan specified that the resident should use eyeglasses to support participation in daily activities. The resident reported not having their glasses and being unable to see, and was observed without glasses in the day room. Staff members were unaware of the resident's need for glasses, and the unit manager initially stated the resident did not wear glasses. Upon further investigation, the resident's glasses could not be located, and the unit manager acknowledged missing this requirement in the care plan. The resident's son confirmed the glasses had been missing for about two months and had requested assistance in replacing them. These deficiencies were identified through observation, interviews, and record review, demonstrating a failure to implement and follow individualized care plans as documented for both residents. The lack of adherence to care plan interventions was confirmed by staff interviews and direct observation, with care plans not being consistently referenced or followed during care delivery.