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 four of fourteen sampled residents, as required by its own policy and federal regulations. For one resident with a history of stroke, difficulty walking, and severe cognitive impairment, there was no documented evidence of a resident-specific care plan, and the existing plan included unachievable interventions such as instructing the resident not to yell at others. Additionally, the care plan was not updated quarterly as required. Interviews with the MDS Coordinator and DON confirmed that a comprehensive care plan should have been implemented upon admission and reviewed regularly. For another resident with dementia and delirium, the behavior care plan addressed incidents such as smearing feces and resident-to-resident altercations only after they occurred, with interventions that were reactive rather than proactive or individualized. Similarly, a resident with depression and anxiety had a care plan listing multiple behavioral concerns, but interventions were implemented only after incidents, such as altercations, had already taken place. Another resident with Alzheimer's disease and severe mental impairment had a care plan that included interventions like redirection and reassurance, but these were also reactive and did not include proactive strategies to prevent recurring behaviors. Interviews with facility leadership, including the DON and Social Services Director, revealed a lack of awareness regarding recurring behaviors and an admission that care plans were not resident-specific or proactively updated. The Social Services Director acknowledged that behavioral issues were previously overlooked and not addressed in care planning, and could not explain why preventive interventions were not included. The DON admitted to not reviewing any resident care plans for a period of time, further contributing to the deficiency.