Failure to Develop and Implement Comprehensive Care Plans for Elopement, Smoking, and Diet Orders
Penalty
Summary
The facility failed to develop and implement appropriate care plan interventions for four residents, resulting in deficiencies related to elopement risk, smoking, and dietary orders. For one resident with dementia and a history of behavioral disturbances, there were multiple documented incidents of attempted elopement, including leaving the facility grounds and packing belongings to go home. Despite these behaviors and a high-risk elopement assessment, an elopement risk care plan was not developed until after a significant incident occurred. Another resident with severe cognitive impairment was identified as high risk for elopement through an assessment, but no corresponding care plan was created to address this risk. A third resident, who was cognitively intact and identified as a tobacco user, was allowed to participate in supervised smoking breaks without a completed "Smoking Observation Form" or a care plan related to smoking. The required assessment and care plan were only completed after the deficiency was identified. Staff interviews confirmed that the resident was "grandfathered in" for smoking privileges, but the necessary documentation and planning were not in place prior to the surveyor's review. For a fourth resident with hemiplegia, dysphagia, and a physician-ordered mechanical soft diet, the care plan specified the correct diet, but staff failed to follow it, resulting in the resident being served a hamburger, which is not considered mechanical soft. This led to a choking incident. Staff interviews confirmed that the resident's dietary needs were documented in multiple locations, including the care plan, but the prescribed diet was not adhered to during meal service.