Failure to Develop Care Plan Addressing Resident's Shower Preference
Penalty
Summary
The facility failed to develop a care plan addressing a resident's expressed preference for female CNAs to provide shower assistance. Despite documentation in the psychosocial progress note and direct communication from the resident to staff, this preference was not incorporated into the resident's care plan. The resident, who had diagnoses of depression, anxiety, moderate cognitive impairment, and physical limitations requiring maximal to total assistance with activities of daily living, communicated his preference to staff after moving rooms and refused a shower when a male CNA was assigned. Multiple staff members, including a CNA and an LVN, were aware of the resident's preference, and the LVN acknowledged that a care plan should have been created to address it. A review of the resident's records confirmed the absence of a care plan reflecting this preference, even though the facility's policies require care plans to address resident choices and preferences. The failure to document and implement the resident's care preference had the potential to delay and negatively affect the delivery of care for the resident's overall wellbeing, as noted by staff during interviews.