Failure to Implement Person-Centered Care Plan for Psychosocial Needs
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan to address the mental and psychosocial needs of a resident with cerebral palsy, severe physical impairment, and anxiety disorder. The resident was dependent on staff for all activities of daily living and had significant cognitive impairment, including both short- and long-term memory loss. The care plan specified that the resident preferred to have the television on at all times, particularly with shows involving animals, as a means of meaningful engagement. However, multiple observations over several days revealed that neither of the two televisions in the resident's room were consistently turned on, and the remote was out of the resident's reach. When the television was eventually turned on, it was not set to the preferred programming as outlined in the care plan. Interviews with staff, including a CNA, the Activities Director, the MDS Director, and the DON, revealed a lack of awareness and monitoring regarding the specific interventions in the resident's care plan. The CNA was unaware that the television should be on at all times or that it should be tuned to animal shows. The Activities Director was not monitoring to ensure the intervention was implemented, and both the DON and Administrator stated that staff were expected to follow care plans as written. Despite these expectations, the care plan was not consistently followed, resulting in a failure to meet the resident's identified mental and psychosocial needs.