Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to communication and sensory needs. For one resident with dementia and diabetes, whose primary language was Korean, the care plan did not address the resident's language barrier. Multiple assessments and interviews confirmed that the resident required or preferred communication in Korean and needed an interpreter for interactions with healthcare staff. Observations showed the resident did not respond to English but did respond to Korean, and both nursing staff and family confirmed the importance of addressing the language barrier in the care plan. Despite this, the care plan lacked any mention of the resident's language needs. For another resident with end-stage renal disease, legal blindness, and bilateral lower limb amputations, the care plan did not address the resident's severe hearing impairment or the use of hearing aids (HA). Documentation and staff interviews confirmed the resident was hard of hearing and required HAs, but the care plan did not include interventions or monitoring related to hearing loss or HA use. The resident reported issues with the provided HA, including discomfort from background noise, and had requested follow-up appointments and updates, which had not been addressed. Staff interviews further revealed that the absence of a care plan for hearing impairment was an oversight, and that such a plan should have been developed. Facility policy required that comprehensive, person-centered care plans be developed within a specified timeframe after assessment, including measurable objectives and timetables to meet each resident's needs. The policy also emphasized the importance of culturally competent care and interdisciplinary team involvement. In both cases, the facility did not follow its own policies and procedures, resulting in the failure to address significant communication and sensory needs in the care plans for these residents.