Failure to Develop and Implement Person-Centered Care Plans for Behavioral Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with documented behavioral issues. For one resident with Alzheimer's disease, generalized anxiety disorder, and colon cancer, the care plan addressed only physical aggression and did not include interventions for frequent verbal and other disruptive behaviors, such as agitation, preaching loudly, and making disruptive sounds. Documentation showed these behaviors occurred regularly, but the care plan lacked specific, individualized interventions or measurable goals for these issues. Additionally, care plan conference forms and weekly nursing summaries often omitted detailed descriptions of the behaviors, and there was no evidence that these behaviors were discussed or addressed in care planning meetings. Another resident with severe cognitive impairment and anxiety disorder also exhibited verbal and physical behaviors, including agitation, pacing, and confrontational statements toward others. Despite these documented behaviors in nursing progress notes and CNA task documentation, the resident's care plan did not address behavioral issues at all. Care plan conference forms similarly failed to document or discuss these behaviors, and there was no evidence of individualized interventions or goals to manage or mitigate the resident's actions. Observations and staff interviews confirmed that both residents regularly displayed behaviors that affected their interactions with others, sometimes leading to altercations. Staff acknowledged that these behaviors were typical for the residents and that care plans should have included specific interventions to guide staff responses. Facility policy required comprehensive, person-centered care plans with measurable objectives and timeframes for all identified needs, but this was not followed for the two residents in question.