Failure to Develop and Implement Comprehensive Care Plan for Resident Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing behavioral concerns for one resident. The resident, who was cognitively intact per a recent BIMS assessment, reported multiple issues with staff, including a medication error by a nurse and dissatisfaction with dietary services. The resident frequently changed food preferences and reported concerns to various staff members, including the DON. Documentation revealed that the resident had a pattern of reporting staff performance issues, resulting in the removal of approximately 15 caregivers from her care. Despite these ongoing behavioral concerns and the impact on staff assignments, there was no care plan in place to address or manage these behaviors. Interviews with facility staff, including the DON and dietary manager, confirmed awareness of the resident's behaviors and the challenges they posed. The DON acknowledged that fabricating issues with staff was a behavior used by the resident to control her care and that a care plan should have been developed to guide staff responses. A review of the resident's records confirmed the absence of a care plan related to these behaviors, contrary to facility policy requiring comprehensive, person-centered care plans with measurable objectives and interventions for each resident.