Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant clinical needs. For one resident with a history of pain, the care plan did not include measurable objectives or goals for pain management, despite multiple physician orders for pain medications and documented complaints of inadequate pain control. The resident reported that pain was not being well managed, leading to an unsanctioned visit to urgent care for further evaluation and recommendations. Facility documentation and staff interviews confirmed that the omission of a pain management care plan was an oversight, and the care plan was not updated in a timely manner to reflect the resident's needs. For another resident with a diagnosis of dementia, the care plan failed to reflect the new diagnosis and did not include interventions to address dementia-related needs. The resident had a history of stroke, fibromyalgia, and chronic pain, and was receiving multiple medications, including antipsychotics and antidepressants. Despite a neurological consult and psychiatric note confirming the diagnosis of dementia with hallucinations and paranoia, the care plan was not updated to include dementia care or related interventions. Staff interviews revealed that the responsibility for updating care plans was not consistently followed, and the care plan did not reflect changes in the resident's condition. Facility policies required the development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for all residents, including those with pain and dementia. The care planning process was to include ongoing assessments and timely updates to reflect changes in residents' diagnoses and needs. However, the facility did not ensure that care plans were updated or comprehensive for the residents reviewed, resulting in deficiencies in meeting their physical, psychosocial, and functional needs.