Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans that addressed all identified needs for seven residents out of twenty reviewed during the annual survey. Surveyors found that care plans often contained only generic interventions and did not include individualized strategies based on each resident's diagnoses, conditions, or personal history. For example, one resident with a stage three pressure ulcer and orders for specific interventions such as a specialty mattress and heel protectors had a care plan that lacked individualized interventions and did not address the resident's inability to use certain equipment as intended. Several residents with mental health diagnoses, trauma histories, or complex medical conditions did not have care plans that addressed the full scope of their needs. One resident with PTSD had a care plan that only referenced access to psychiatry and psychosocial services, without identifying triggers or specific interventions to prevent re-traumatization. Another resident with a history of trauma and anxiety related to loud noises had no care plan addressing these issues, despite the resident's own report of distress and coping strategies. Additionally, residents with multiple comorbidities, such as heart failure, hypertension, diabetes, and recent fractures, had care plans that omitted key diagnoses and related interventions, such as cardiovascular disease management, pain control, or pressure ulcer prevention. Observations and interviews confirmed that care plans were incomplete or not individualized, and that staff, including the DON, acknowledged these deficiencies. In some cases, care plans did not address significant medical issues such as viral hepatitis, cirrhosis, depression, insomnia, or the use of medical devices like indwelling catheters and wound vacs. The lack of comprehensive care planning was evident through both documentation review and direct observation of residents and their care environments.