Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical and psychosocial needs. The resident, an elderly female with diagnoses including benign intracranial hypertension, mixed hyperlipidemia, Type 2 diabetes with hyperosmolar hyperglycemic coma, intermittent explosive disorder, cognitive communication deficit, and unspecified dementia, was admitted with significant cognitive impairment as evidenced by a BIMS score of 00. The comprehensive assessment identified several care areas requiring attention, such as cognitive loss/dementia, communication, urinary incontinence, behavioral symptoms, falls, nutritional status, pressure ulcers, and psychotropic drug use. Despite these identified needs, the resident's care plan did not address several critical areas, including cognitive loss/dementia, communication, urinary incontinence, behavioral symptoms, and pressure ulcers. Additionally, the care plan failed to include the physician's order for a wander guard or the rationale for its use, and did not address the resident's behaviors related to her diagnoses. Observations confirmed the presence of a wander guard and ongoing behavioral symptoms, such as repeated tapping, yet these were not reflected in the care plan. Interviews with staff revealed a lack of awareness regarding the incomplete care plan and uncertainty about whether all required care areas were included. The facility's policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for each resident. However, the care plan for this resident was incomplete and did not reflect all areas identified in the comprehensive assessment. Staff interviews indicated that care plans were supposed to be updated upon admission, quarterly, and as changes occurred, but the process was not fully implemented, resulting in the omission of essential care planning for the resident.