Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement and develop comprehensive care plans tailored to the individual needs of several residents, as evidenced by multiple observations and interviews. For one resident with severe cognitive impairment and total dependence for activities of daily living (ADLs), staff placed a bedside table and lowered the bed frame in a manner that restricted movement and created a risk of entrapment. Both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that these actions were inappropriate and not in line with the resident's care plan, which aimed to prevent signs and symptoms of entrapment. Another resident with unspecified dementia and psychosis, who was nonverbal and required supervision for ADLs, was observed wandering the facility and attempting to enter other residents' rooms. Despite the use of a sitter to monitor this resident's behavior, there was no care plan developed to address the risk of elopement or behavioral concerns. Both the LVN and DON acknowledged the absence of a care plan for this resident's behavior. A third resident, also with severe cognitive impairment and total dependence for ADLs, was observed in uncomfortable and unsafe positions in bed, with a tendency to slide off the bed. Staff interviews indicated the need for frequent monitoring and specific positioning due to tube feeding requirements, but there was no care plan developed to address the resident's behavior of sliding off the bed. The facility's policy requires comprehensive, person-centered care plans with measurable goals and timetables, which were not implemented for these residents.