Failure to Develop and Implement Person-Centered Care Plan Reflecting Resident Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with specific preferences and needs identified in their assessment. The resident, a male with vascular dementia, hypertension, hemiplegia, hemiparesis, and lack of coordination, was admitted with moderate cognitive impairment. A Social Services Quarterly Assessment documented that no male CNAs should be in the resident's room, following an allegation of sexual abuse involving a male CNA. However, this preference was not reflected in the resident's care plan, and there was no documentation to ensure the preference was communicated or implemented. Multiple staff interviews revealed inconsistent awareness and understanding of the resident's preference regarding male CNAs. Some staff recalled being told verbally not to allow male CNAs in the resident's room, while others were unaware of any such instruction or the reason behind it. The social worker, who completed the assessment, was no longer employed, and the current social worker was unaware of the preference or its origin. Nursing staff and administration acknowledged that the information should have been included in the care plan but was not, and there was no documentation of the incident or the instructions given to staff. The facility's policy requires that each resident have a person-centered comprehensive care plan developed and implemented to meet their preferences and needs. Despite this, the resident's care plan did not address the documented preference for no male CNAs, and there was a lack of communication and documentation among staff to ensure the resident's needs and preferences were met as identified in the assessment.