Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for five residents, resulting in unmet care needs and lack of guidance for staff. For one resident with dementia, alcohol dependence, and heart failure, who was assessed as high risk for elopement due to daily wandering and verbalizing a desire to leave, the care plan required constant monitoring. However, the resident was not included in hourly monitoring rounds, and there was no documentation of monitoring, despite staff acknowledging the necessity of these interventions. Another resident with diagnoses including depressive disorder, diabetes, vascular dementia, and PTSD did not have a care plan addressing PTSD, even though the resident's records and physician orders indicated the presence of this condition. Staff interviews confirmed that the absence of a PTSD care plan meant that staff were not informed about how to provide appropriate trauma-informed care or avoid known triggers, as required by facility policy. Additionally, three residents who smoked did not have baseline smoking care plans in place, despite their participation in supervised smoke breaks and documented cognitive impairments. Staff interviews and facility policy confirmed that all residents who smoke should have individualized care plans to ensure safety and appropriate supervision. The lack of these care plans meant that staff did not have clear instructions on how to manage the residents' smoking activities safely.