Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for three residents. One resident, who was cognitively intact but had severe visual impairment, expressed a strong preference for specific activities such as listening to music, keeping up with the news, participating in group activities, and going outside. Despite these preferences being documented in the MDS, the care plan did not reflect them, and the resident was observed sitting in her room with minimal activity involvement. Additionally, this resident had an active order for TED hose due to lower extremity edema, which was not addressed in the care plan, and the resident reported not wearing the hose since admission, despite ongoing documentation of edema in weekly assessments. Another resident with severe cognitive impairment, hemiplegia, and contractures was dependent on staff for all activities of daily living and had pressure ulcers. Observations revealed that this resident was not consistently provided with pressure-relieving devices between the knees, and there was no care plan specifically addressing contractures or pressure relief. Staff interviews confirmed the absence of such a care plan, despite the resident's significant physical limitations and risk factors. A third resident, who was severely cognitively impaired and dependent on staff for mobility and ADLs, had documented preferences for a variety of activities, including religious services, music, and group events. However, the care plan did not address the resident's activity needs or participation, even though assessments indicated these were very important to the resident. Staff interviews confirmed that an activities care plan should have been in place but was not developed.