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 multiple residents, as required by regulation and facility policy. Surveyors found that for 16 out of 32 residents reviewed, care plans were either incomplete, lacked measurable objectives and timeframes, or were not implemented as written. Specific deficiencies included missing care plans for identified medical needs such as foot care, vascular wounds, infections, abscesses, conjunctivitis, and pressure ulcers. In several cases, care plans did not address person-centered interventions for conditions like diabetes management, behaviors, dementia, mood, and malnutrition risk. For example, one resident with a diagnosis of atrial fibrillation, diabetes, and dysphagia had a care plan for risk of abuse that contained no interventions. Another resident, who was severely cognitively impaired and at risk for falls, experienced multiple falls when interventions such as floor mats and low bed positioning were not in place as directed by the care plan. Additionally, a resident with dementia and diabetes developed a pressure sore that progressed in severity, but the care plan was not updated to reflect changes in skin condition or to address the risk for pressure ulcers. In some cases, care plans did not include documentation of the resident's use of dentures or specific interventions for abuse prevention and safety concerns. Interviews with nursing staff revealed a lack of awareness regarding the absence or non-implementation of care plan interventions, as well as issues with communication and workload. Staff responsible for care planning indicated that interventions were not always communicated to certified nursing assistants, and that updates to care plans were not consistently made following changes in residents' conditions. The facility's policy required care plans to be current, realistic, and individualized, but these standards were not met for the residents reviewed.