Failure to Develop and Implement Comprehensive Care Plans for Resident Needs
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans for two residents with specific needs. One resident, admitted with diagnoses including major depression, substance abuse, and muscle weakness, consistently refused to allow nursing staff to clean his room, nightstand, or closet, and would not permit staff to make his bed or change his linen. Despite these ongoing refusals, there was no documented care plan outlining how staff should address or manage the resident's refusals regarding room cleanliness and personal space. Staff interviews confirmed that the resident's preferences were not addressed in the care plan, and the facility's protocol for daily cleaning was not followed for this resident due to his refusals. Another resident, admitted with a history of falls, muscle weakness, obesity, and a stage 3 sacral pressure ulcer, was totally dependent on staff for activities of daily living and mobility. This resident required the use of a mechanical lift and assistance from at least two staff members for transfers out of bed. However, a review of the care plan revealed that it did not address the use of a mechanical lift for transfers. Staff interviews confirmed that the mechanical lift was used for this resident, but this intervention was not documented in the care plan.