Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents, resulting in uncommunicated care needs. For one resident with diagnoses including dementia, depression, cognitive communication deficit, and lack of coordination, the care plan did not include specific directions regarding personal hygiene preferences, particularly shaving. Despite the resident expressing a preference to be shaved daily and not to grow a beard, staff only provided shaving on shower days, and there was no documentation of his preference in the care plan or Kardex. Staff interviews confirmed that personal hygiene preferences were not clearly communicated or accessible, and observations over several days showed the resident with unshaven facial hair. Another resident with dementia, congestive heart failure, abnormal lung findings, and hypoxia had a care plan that lacked direction for oxygen therapy and the use of a BiPAP machine at bedtime, despite physician orders for these interventions. The care plan only noted the presence of equipment supplied by hospice but did not specify how or when to use the oxygen or BiPAP. Observations showed the resident using oxygen, but the tubing was not stored properly when not in use. Staff interviews revealed uncertainty about the correct oxygen flow rate and confirmed that respiratory care needs were not included in the care plan. The facility's policy required timely, person-centered, comprehensive care plans developed and revised by an interdisciplinary team with input from the resident or their representative. However, both residents' care plans lacked essential individualized information, and staff were not consistently aware of or able to access the residents' specific care preferences and needs, as evidenced by direct observation, record review, and staff interviews.