Failure to Develop Resident-Specific Care Plans for Hygiene and Hospice Needs
Penalty
Summary
The facility failed to develop and implement individualized care plans that addressed specific care needs for three residents. For one resident with a history of stroke and traumatic brain injury who was dependent on staff for personal hygiene, there were no care plan interventions or instructions related to nail care, despite observations of unclean fingernails. Staff interviews confirmed that care plans should include such interventions, but this was not present in the resident's documentation. Another resident, who was cognitively intact and required assistance with personal hygiene, expressed a preference for being shaved by their spouse, with staff to assist if the spouse was unavailable. However, the care plan and Kardex lacked instructions regarding this preference, and staff were unaware or did not consistently offer shaving assistance. Additionally, a resident on hospice care with moderate cognitive impairment had no care plan interventions specifying the division of care responsibilities between facility staff and hospice, nor was hospice contact information included. Staff acknowledged that this information was missing and should have been documented.