Failure to Provide Individualized and Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized, and person-centered care plans for 11 of 18 sampled residents. Surveyors found that care plans were often generic, not updated, and lacked specific interventions or measurable goals tailored to each resident's unique needs and diagnoses. For example, one resident with dementia and depression had a care plan that did not address meal refusals or provide alternatives, and another resident's care plan listed an incorrect diagnosis for anti-anxiety medication. Staff interviews confirmed that care plans were not individualized and did not reflect current conditions or effective interventions. Several residents with complex medical histories, such as malnutrition, chronic pain, kidney disease, and end-of-life care needs, had care plans that were either missing critical information or were not updated to reflect significant changes in their health status. For instance, a resident with chronic pain did not have a care plan specifying pain goals, effective medications, or non-pharmacological interventions, and another resident with significant weight loss did not have this issue addressed in their care plan. Additionally, residents receiving palliative or end-of-life care had care plans that were described as 'cookie cutter,' lacking any individualized preferences, goals, or interventions. Other deficiencies included the absence of care plans for specific conditions observed during the survey, such as senile purpura, constipation, and the use of safety devices like bed placement against the wall. Staff acknowledged that these omissions meant care plans did not guide staff on how to address residents' specific needs or preferences. The lack of individualized, updated, and comprehensive care plans placed residents at risk of unidentified and unmet care needs.