Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for three residents, resulting in deficiencies related to communication, safety, and clinical care. For one resident with muscle weakness, schizophrenia, and diabetes, there was a physician's order for the use of half side rails as an enabler for self-positioning and bed mobility. However, no care plan was created to address the use of side rails, including necessary interventions to monitor for entrapment risks, despite facility policy requiring assessment and care planning for bed rail use. Another resident with severe cognitive impairment, cerebral infarction, and right-sided hemiplegia had a care plan that noted a communication problem due to a language barrier, but the care plan did not specify the resident's preferred language of Spanish. Staff interviews confirmed that the omission of the preferred language in the care plan could hinder effective communication and the use of appropriate communication aids or interpreters. A third resident with quadriplegia, multiple joint contractures, and severe cognitive impairment had physician orders for passive range of motion (PROM) exercises and the use of splints. Despite these orders and the resident's significant physical limitations, there was no care plan in place to address contractures, limited range of motion, or the maintenance program until several months after the orders were written. Staff acknowledged that the absence of a care plan meant that interventions and goals for the resident's contractures and ROM could not be consistently communicated or reviewed among the care team.