Failure to Develop and Implement Comprehensive Care Plans for Residents with Contracture and Behavioral Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, one with a contracture and another exhibiting disruptive behaviors. For the first resident, who was admitted with dementia, cerebral infarction, and adult failure to thrive, an admission observation identified a right-hand contracture. However, the care plan did not address this contracture, nor did it specify therapeutic or nursing interventions or functional goals. The Minimum Data Set (MDS) also failed to document the contracture, and the MDS Coordinator was unaware of its presence due to this omission. Facility policy requires individualized care plans for contractures, including specific interventions and goals, but this was not followed in this case. For the second resident, who had schizoaffective disorder and PTSD, the care plan included general interventions for anxiety and mood swings and instructions regarding smoking, but did not address the management of escalating or disruptive behaviors. An incident was observed where the resident became agitated and verbally aggressive after being denied a nicotine lozenge until after a shower. The assigned LPN did not implement any interventions to de-escalate the situation and was unable to articulate appropriate actions to address the resident's behavior. The nursing supervisor was not notified of the incident, and staff interviews revealed a lack of clarity regarding behavioral interventions for this resident. The facility's failure to develop and implement individualized, comprehensive care plans for both residents resulted in unmet needs related to contracture management and behavioral support. Staff were either unaware of the residents' specific conditions or unable to describe or implement appropriate interventions, contrary to facility policy and expectations for interdisciplinary care planning.