Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents as required by its own policies and federal regulations. For one resident at risk for falls due to cognitive loss and lack of safety awareness, the care plan specified the use of bilateral floor mats. However, during multiple observations, only one floor mat was in place, and the other side of the bed was left without a mat, contrary to the care plan's interventions. This failure was confirmed by the Director of Staff Development (DSD) during an interview and observation. Additionally, the facility did not create care plans to address the use of dementia medications (Aricept and Namenda) for another resident, despite physician orders for these medications. The Assistant Director of Nursing (ADON) confirmed that a care plan should have been initiated for these medications but was missed. Another resident with documented depressive symptoms and ongoing psychological evaluation and treatment also lacked a care plan addressing these mental health needs. The ADON verified that the care plan problem for depressive signs and symptoms was not developed as required.