Failure to Develop and Implement Person-Centered Care Plans for Behavioral and Positioning Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with identified needs. For one resident with dementia, anxiety disorder, and Alzheimer's disease, the care plan noted wandering and intrusive behaviors but did not include specific interventions for known aggressive behaviors, despite documentation of an incident where the resident hit another resident. Staff interviews confirmed that the behaviors were known prior to the incident and should have been addressed in the care plan, but appropriate interventions were not included or updated as required by facility policy. For another resident with right-sided paralysis and a physician's order to wear a right-hand splint, the care plan required the splint to be worn continuously and for staff to assist as needed. However, records showed multiple refusals by the resident to wear the splint, and staff were inconsistent in offering or reminding the resident to use it. Interviews revealed confusion among staff regarding responsibility for applying the splint and a lack of awareness about the need to remind the resident, despite the physician's order. The care plan did not address the resident's refusals, and the facility's policy required nursing staff to ensure proper use and care of splinting devices.