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 two residents, as required by facility policy and federal regulations. For one resident with diagnoses including multiple sclerosis, dementia with behavioral disturbance, insomnia, and substance abuse, the care plan did not address behavior monitoring or insomnia, despite physician orders for antipsychotic medication (Seroquel) for these indications. The care plan also lacked documentation of non-pharmacological interventions for insomnia, and there was no evidence that the resident had been offered or had refused psychiatric services prior to the survey. Interviews with facility staff revealed a lack of clarity regarding the need for behavior care plans and non-pharmacological interventions, even when behavior monitoring was ordered by the physician. For another resident with a history of a left humerus fracture and COPD, the facility failed to implement a fall prevention intervention as determined by the interdisciplinary team (IDT) after a fall event. The IDT identified that placing dycem under the legs of the resident's recliner would address the root cause of the fall, and this intervention was added to the care plan. However, multiple observations over several days confirmed that the dycem was not present under the recliner. Additionally, the CNA care guide used by staff was not updated to reflect this intervention, and staff interviews indicated a lack of awareness or follow-through regarding the intervention's implementation. The deficiencies were further compounded by gaps in communication and documentation. The CNA care guide, which staff relied upon for resident care, was not promptly updated with new interventions, and there was no clear accountability for ensuring that care plan changes were implemented and maintained. Staff interviews revealed inconsistent understanding of care plan requirements and the process for updating and communicating interventions, contributing to the failure to meet residents' identified needs as outlined in their comprehensive assessments.