Failure to Develop and Implement Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for four residents, resulting in unmet needs related to activities of daily living (ADLs), oral/dental care, smoking, and management of post-traumatic stress disorder (PTSD). For one resident, care plans addressing compliance with ADLs and oral/dental care were not properly implemented. Observations revealed the resident had a dry crust around the lips and significant buildup and discoloration on the teeth. Interviews with staff indicated that while oral hygiene supplies were provided, there was no follow-through to ensure the resident completed oral care, and staff were not instructed to monitor or prompt the resident as required by the care plan. Another resident who smoked did not have a care plan addressing smoking, despite documentation of nicotine dependence and a facility policy requiring such a plan. The resident was observed smoking under staff supervision, but both the RN and DON confirmed that a care plan for smoking was missing. Facility policy specified that a care plan should be in place to address nicotine dependence, safety, and smoking cessation education, but this was not done. Two additional residents with documented diagnoses of PTSD did not have care plans addressing this condition. Both residents' records and care plans were reviewed, and it was confirmed by nursing staff and the DON that care plans for PTSD were not created. Facility policy required the development of trauma-informed care plans when trauma was identified, but this was not followed. The lack of appropriate care plans for these residents meant that their specific needs related to PTSD were not addressed, and staff did not have guidance for managing symptoms or providing consistent care.