Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed all identified needs for multiple residents. For one resident with dementia, observations and interviews revealed complaints of not being treated with dignity and respect, and reports from the resident's daughter indicated that staff were sometimes rough. Despite these behavioral concerns and allegations, there were no care plan interventions in place to address the resident's behaviors or false allegations, even though the care plan included other risks such as falls and communication deficits. The Director of Nursing acknowledged that these behaviors should have been care planned but were not. For another resident with multiple diagnoses including COPD, dementia, schizophrenia, CVA, diabetes, epilepsy, and heart failure, a plan of care was initiated to review functional abilities, but no interventions were included. Additionally, there was no care plan in place for limited range of motion until after an interview with the DON. The facility only had a partial restorative program in place, limited to dining activities. Other residents with complex medical histories, such as those on hospice, with indwelling catheters, or at risk for elopement, also lacked care plans addressing key aspects of their care, such as safe smoking practices, oxygen therapy, dementia, communication deficits, and disease-specific interventions. Record reviews and staff interviews confirmed that care plans were either missing, incomplete, or not updated to reflect the residents' current needs and conditions. The DON acknowledged that the care plans did not directly address the residents' care needs, resulting in a failure to provide a comprehensive care plan process for six out of twenty-one residents reviewed.