Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents. For one resident with Guillian-Barre Syndrome and no cognitive impairment, the care plan did not address food preferences, despite physician orders for a regular diet with large portions and the resident's report of not liking the food and experiencing weight loss. The Registered Dietician confirmed that dietary preferences were not reviewed or included in the care plan as required. For another resident with hemiplegia, muscle weakness, and severe cognitive impairment, the facility did not implement a care-planned intervention to reduce fall risk. The care plan specified that the bed should be in a low position, but observations on multiple occasions found the bed was not in the low position while the resident was in bed. An LPN was unaware of the fall intervention, and the resident confirmed the bed was only lowered on the day of the survey. The Director of Nursing stated that care-planned interventions are expected to be followed every time.