Failure to Develop Care Plan for Visitation Rights and Family Conflict
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing a resident's visitation rights and the conflict between the resident's family members. The resident, who had diagnoses including respiratory tuberculosis, pneumonia, and depression, was assessed as having severely impaired cognitive skills and required moderate assistance with activities of daily living. Despite documentation in the Interdisciplinary Team (IDT) notes that certain family members were not allowed to visit unless accompanied by another family member, there was no corresponding care plan developed to address this issue. Progress notes indicated that the facility was informed by the Ombudsman that visitation could not be restricted unless there was an immediate risk to the resident, and staff interviews confirmed that no harm or neglect had occurred from the restricted family members. Further review revealed that the facility's policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's needs, but no such plan was created regarding the visitation conflict. Both the Social Services Director and a Registered Nurse acknowledged the lack of a care plan for the resident's visitation rights and family conflict, confirming that the facility did not follow its own policies and regulatory requirements in this instance.