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 two residents, resulting in unmet care needs. For one resident with multiple diagnoses including congestive heart failure, diabetes, and pulmonary fibrosis, the care plan did not include essential details related to dialysis care. Missing elements included the dialysis center's contact information, specifics on monitoring pre- and post-dialysis vitals, transportation arrangements, the type and location of dialysis, which arm to use for blood pressure, emergency contacts for dialysis-related issues, and monitoring for complications such as infection or hypotension at the access site. Another resident with cognitive impairment, ataxia, and a history of traumatic brain injury experienced repeated elopement incidents. The care plan did not identify the resident's elopement risk or outline interventions to prevent further incidents, nor did it include person-centered activities or diversions tailored to the resident's interests or dementia progression. Despite multiple documented elopements and discussions about transferring the resident to a secure unit, the care plan was not updated to reflect these risks or interventions.