Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, resulting in deficiencies related to unmet care needs. For one resident with dementia, muscle weakness, and bipolar disorder, the care plan did not address her use of a wireless handheld call light device, despite her history of hiding the corded call light and her preference for the wireless option. Observations confirmed that the resident did not have access to a call light in her room, and staff interviews revealed that the use of the wireless device had been ongoing for over a month but was not reflected in the care plan. Staff acknowledged the importance of individualized care plans and the necessity of documenting specific interventions, such as the use of alternative call light systems, to ensure all staff are informed of each resident's needs. Another resident with muscle wasting and protein-calorie malnutrition, who was unable to complete a cognitive interview, was on meal monitoring due to weight loss. Documentation showed that this resident consistently consumed less than 75% of meals, and while staff offered meal alternatives and supplements, these were frequently refused. However, there was no care plan in place that addressed interventions for when the resident refused supplements or alternatives. Staff and the DON confirmed that interventions were not clearly defined or specific to this problem, and that care plans should have included strategies for addressing refusals to ensure the resident's nutritional needs were met. The facility's policy required comprehensive, person-centered care plans that incorporate identified problem areas, risk factors, and resident preferences, with measurable objectives and interventions. In both cases, the lack of individualized and updated care plans led to inconsistent care and failure to address the residents' specific needs as observed and confirmed by staff and record review.