Failure to Develop Comprehensive ADL Care Plan for Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive, resident-centered care plan with measurable objectives and interventions for Activities of Daily Living (ADL) for one resident. The resident had multiple diagnoses, including dementia, bipolar disorder, schizoaffective disorder, and major depressive disorder, and was documented as having moderately to severely impaired cognition over time. Despite assessments indicating a risk for alterations in ADL function and the need for interventions, the resident's care plan did not include an ADL care area or specific interventions. Documentation showed that the resident did not receive showers for extended periods, with records indicating missed showers over several days in April, May, and June, and only two documented refusals. Observations revealed the resident was repeatedly unshaven and had disheveled hair. Administrative staff confirmed the absence of an ADL care plan for the resident, despite facility policy requiring individualized, comprehensive care plans to address each resident's needs.