Failure to Individualize ADL Care Plan for Resident with Self-Care Deficits
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for a resident with significant ADL self-care performance deficits. The resident, who had diagnoses including local skin infection, falls, anxiety, depression, hypertension, bipolar disorder, sepsis, and dysphagia, was assessed as severely cognitively impaired and requiring substantial assistance with multiple ADLs such as dressing, hygiene, toileting, and bathing. The care plan in place noted the need for assistance by one staff member but did not specify the resident's preferences regarding the type and frequency of bathing. During interviews, the DON confirmed that care plans were created using an interdisciplinary approach and acknowledged that the omission of the resident's bathing preferences was a deficiency. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes based on the resident's assessment, but this was not fully implemented for the resident in question.