Failure to Implement and Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six residents, resulting in unmet care needs. For two residents with significant mobility impairments, scheduled showers were not provided as care planned. One resident reported receiving only one shower per week instead of the two scheduled, and another stated showers occurred as infrequently as once a month. Documentation confirmed that both residents received fewer showers than care planned, and staff interviews attributed this to short staffing. The care plans for both residents specified assistance with bathing on set days, but these interventions were not consistently carried out. In another instance, a resident requiring a two-person assist for transfers with a ceiling lift was left suspended in the air and unattended when the lift malfunctioned. The CNA involved did not have a second staff member present during the transfer, contrary to the care plan and facility policy, and left the resident alone while seeking help. This was confirmed by observation and staff interviews, which acknowledged the expectation for two-person assistance during such transfers. Additionally, two residents with impaired mobility were not repositioned as frequently as required by their care plans, with observations showing prolonged periods without repositioning and documentation indicating only two repositioning events in a day. One of these residents developed a wound on the hip, which was not properly dressed as ordered. Another resident with a diagnosis of COPD did not have a care plan addressing this condition, despite having provider orders for related medications. Staff interviews confirmed that a care plan for COPD should have been in place. These failures were documented through record reviews, observations, and staff and resident interviews.