Failure to Develop Resident-Centered Care Plans for Behavioral Needs
Penalty
Summary
The facility failed to develop and implement resident-centered care plans for two residents with specific behavioral needs. For one resident with Alzheimer's disease and a history of wandering, documentation showed the resident had severely impaired cognitive skills and was at moderate risk for elopement, with a pattern of wandering into other residents' rooms. Despite staff observations and assessments indicating this ongoing behavior, there was no care plan in place to address or manage the wandering, as confirmed by both a CNA and an LVN during interviews and record reviews. Another resident, diagnosed with depression and chronic kidney disease, had intact cognitive skills but repeatedly called 911 for medical concerns without notifying facility staff. Nursing progress notes documented multiple instances where the resident called emergency services and was transferred to a hospital without staff being informed beforehand. Despite these repeated incidents, there was no care plan developed to address this behavior, as confirmed by both an RN and the Quality Assurance Nurse during interviews and record reviews. Facility policy required that care plans be developed for changes in condition and that a comprehensive care plan be created within seven days of the resident assessment. However, in both cases, the required care plans addressing the residents' specific behaviors were not present, contrary to facility policy and staff expectations. This lack of care planning was identified through observation, interviews, and record reviews.