Failure to Develop and Implement Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans for several residents with complex medical and behavioral needs. For one resident with paranoid schizophrenia and a history of aggression, there was no care plan addressing verbal and physical aggression until after an incident where the resident struck another resident. Staff interviews confirmed that aggressive behaviors were known but not care-planned in a timely manner, leaving staff without guidance on interventions to prevent further incidents. Another resident with multiple psychiatric and medical diagnoses, including schizoaffective disorder, diabetes, and atrial fibrillation, was receiving several high-risk medications such as antipsychotics, antidepressants, anticoagulants, and insulin. However, there were no care plans addressing the use of these medications, their side effects, or the necessary monitoring required for each. Staff acknowledged that care plans should have been in place to guide monitoring and interventions for both the medications and the behaviors they were intended to treat. Additional deficiencies included the lack of care plans for residents with refusals of care (such as showering), use of dentures, and for those at risk of decline in activities of daily living (ADLs) due to conditions like stroke or dementia. In each case, staff interviews and record reviews confirmed that care plans were either missing or incomplete, failing to address the residents' specific needs, diagnoses, and required interventions. Facility policies required comprehensive care plans with measurable goals and timetables, but these were not consistently developed or implemented for the affected residents.