Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans for four residents, as required by its own policy and federal regulations. For one resident with diagnoses including Schizophrenia, Viral Hepatitis, and severe cognitive impairment, the care plan did not include any interventions related to Viral Hepatitis, despite the diagnosis being present in the medical record. Another resident with PTSD, Major Depressive Disorder, and Vascular Dementia, and severely impaired cognition, did not have PTSD addressed in the care plan, even though staff confirmed it should have been included. A third resident, who had Diabetes, Anxiety, malignant neoplasms, moderate cognitive impairment, and was receiving hospice services, had no hospice-related interventions documented in the care plan. The fourth resident, with Neuropathy, Anxiety, Dementia, and a history of elopement, had a physician order for a wander guard and documented elopement risk behaviors, but the care plan did not address elopement risk or the use of a wander guard. Staff interviews confirmed that these omissions were not in line with facility policy and expectations for care planning.