Failure to Develop and Implement Person-Centered Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans for four residents, each with specific needs that were not addressed according to their medical conditions and assessments. For one resident with severe cognitive impairment and diagnoses including dementia, depression, and schizoaffective disorder, the care plan did not include interventions or monitoring related to dementia-related behaviors, despite the resident receiving antipsychotic and antidepressant medications. Staff interviews confirmed the absence of a dementia-specific care plan and acknowledged that such a plan should have been in place to guide care and interventions. Another resident with severe cognitive impairment and major depressive disorder was prescribed escitalopram oxalate for depression, but the care plan did not address how the resident would be monitored for side effects or supervised while on this medication. Staff confirmed that the lack of a medication-specific care plan meant that potential side effects or behavioral changes could go unmonitored, and the care plan did not reflect the necessary guidance for staff to provide appropriate care. A third resident, with a recent history of urinary tract infection (UTI) and sepsis, did not have a care plan developed to monitor for signs and symptoms of UTI or to implement interventions to prevent recurrence. Staff interviews revealed that no care plan was created upon the resident's readmission, and as a result, there was no structured approach to monitoring or prevention. Additionally, a fourth resident with left-sided hemiplegia, contracture, and a history of consistent refusals of restorative nursing aide (RNA) services did not have a care plan or interdisciplinary team (IDT) conference to address the refusals, investigate the reasons, or update interventions. Staff acknowledged that the pattern of refusals was known but not formally addressed through care planning or IDT processes.