Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans that addressed the medical, physical, mental, and psychosocial needs of three residents with severe cognitive impairment. For one resident with Parkinson's Disease and a history of frequent falls, observations revealed repeated unsafe situations, such as being left unsupervised in a high bed with cluttered surroundings and having multiple falls since admission. The care plan included several interventions, but staff interviews indicated a lack of awareness and understanding of these interventions, with some staff unable to access or describe the care plan. Despite ongoing falls, there was no evidence that the effectiveness of interventions was evaluated or that staff were consistently informed of changes. Another resident with anoxic brain damage and aphasia was observed with significant facial bruising, but the care plan did not include any focus, goals, or interventions related to the injury or its monitoring. Staff interviews revealed that the incident was known among staff, but there was no documentation in the care plan to address the injury or prevent recurrence. The lack of care plan updates following significant changes in the resident's condition demonstrated a failure to ensure comprehensive and responsive care planning. A third resident with severe cognitive impairment and behavioral issues had a care plan that addressed a single aggressive incident but did not include additional focuses, goals, or interventions for subsequent behavioral episodes, such as confusion and entering another resident's bed. Staff responsible for updating care plans relied on daily order reports and verbal communication, but there was no systematic process to ensure all relevant staff were informed of care plan changes. The facility's policy required measurable objectives and timely updates, but interviews and documentation showed these requirements were not consistently met.