Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, resulting in unmet medical, physical, mental, and psychosocial needs. For one resident with vascular dementia, hemiplegia, and incontinence, the care plan addressed incontinence and skin integrity, but observations revealed improper peri-care technique by a CNA, including wiping from back to front, which was acknowledged as incorrect by both the CNA and the DON. This improper technique was observed during a brief change, and new areas of skin breakdown were identified, despite the care plan's goal to prevent such issues. Interviews with staff confirmed inconsistent knowledge and application of proper peri-care procedures, and the resident's care plan did not fully address her needs or prevent the decline in skin condition. Another resident, whose preferred language is Vietnamese, did not have a care plan that included a person-centered communication plan or interpreter services, despite this being identified as a need. This omission meant that the resident's communication preferences and needs were not accurately reflected or addressed in her care plan, potentially impacting her ability to communicate effectively with healthcare staff. A third resident with a history of trauma and mental health diagnoses did not have a trauma-informed care plan that included identified triggers and specific interventions, even though the facility's policy required such plans. The resident's psychosocial evaluation documented anxiety related to large crowds, but this was not incorporated into the care plan. The lack of individualized, comprehensive care planning for these residents resulted in deficiencies that placed them at risk for a decline in their quality of life and prevented them from attaining their highest practicable well-being.