Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop an individualized care plan for a resident diagnosed with dementia, epilepsy, and generalized anxiety disorder. The resident was admitted with fluctuating mental capacity and required maximal assistance with activities of daily living, including dressing, toileting, personal hygiene, transfers, and bed mobility. Documentation reviewed included the resident's admission record, history and physical, Minimum Data Set, and psychiatric notes, all of which indicated significant cognitive and functional impairments, such as impaired judgment, concentration, and attention span, as well as a blunt or constricted affect. Interviews with nursing staff confirmed that no care plan addressing the resident's dementia had been created. Both an LVN and an RN acknowledged the importance of having an individualized care plan to guide staff in providing appropriate interventions and care for the resident. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not implemented for the resident in question.