Failure to Develop Comprehensive Care Plan for Resident's Independent Outings
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident who was cognitively intact and had a diagnosis of hypertension. The resident was able to leave the facility independently in a motorized wheelchair and enjoyed spending time outside. Facility policy required residents to sign out when leaving the premises, but documentation showed that the resident sometimes signed themselves out, while at other times staff signed out on their behalf. There were instances where the resident left the facility without signing out or alerting staff, as noted in nurse documentation and staff interviews. Despite the resident's established pattern of independent outings and the need for adherence to the sign-out protocol, the care plan did not address the resident's ability to sign out, their enjoyment of outdoor activities, or the need for staff involvement in the sign-out process. Interviews with staff, including the DON and care plan coordinator, confirmed that these aspects were not included in the resident's care plan, and the care plan coordinator acknowledged the omission.