Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for two residents. For one resident, who was admitted with a thoracic vertebra fracture and had moderate cognitive impairment, range of motion limitations, and was totally dependent on staff for transfers, there was no care plan addressing his use of a gait belt secured across his wheelchair. Observations and interviews revealed that the resident used the gait belt to prevent himself from falling out of the wheelchair, and staff, including the DON, DCO, PT, and Administrator, were aware of this practice. However, none of them identified it as a risk or ensured it was addressed in the care plan. For another resident, who had chronic respiratory failure, Alzheimer's disease, and recurrent C. difficile infections, there was no care plan addressing her contact isolation status. This resident was cognitively intact, required moderate assistance with most ADLs, was frequently incontinent, and was receiving antibiotics. Despite her need for isolation due to recurrent infections, the care plan did not include any interventions or objectives related to her isolation status. The facility's own policy requires the development and implementation of a comprehensive, person-centered care plan for each resident, including measurable objectives and timetables to meet their needs. In both cases, the facility did not follow its policy, resulting in the absence of care plans for significant aspects of the residents' care, specifically the use of a gait belt as a restraint and the management of contact isolation.