Failure to Follow and Develop Comprehensive Care Plans for Resident Needs
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, involuntary movements, and osteoarthritis, who was totally dependent on staff for personal hygiene, transfers, toileting, and bed mobility, did not receive care according to their individualized care plan. The care plan and care card specified that two staff members were required to assist with all care, including bed mobility. However, a nursing assistant was observed providing care alone, despite being aware of the two-person assistance requirement. This deviation from the care plan was identified during an investigation into an injury of unknown origin, specifically a fractured left thumb, which may have resulted from care being provided by only one staff member. Another deficiency was identified for a resident with acute respiratory failure, hypoxia, pneumonia, and insomnia. The resident was cognitively intact and required oxygen therapy. The care plan for this resident did not include any interventions to address respiratory care needs, nor did it document any behaviors related to refusal of care. Nursing staff acknowledged that the omission of respiratory interventions was an oversight and that all residents on oxygen should have a care plan addressing this need. Additionally, the same resident was observed using hearing aids, but the care plan did not include interventions for the care or maintenance of the hearing aids. Staff interviews confirmed that the facility is responsible for the care and maintenance of hearing aids and that this should have been included in the care plan. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, but these requirements were not met for the residents in question.