Failure to Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to the delivery of prescribed care. For one resident with a persistent vegetative state and contractures, the care plan required the use of left and right hand splints and knee splints daily for six days a week, with specific timeframes for application. However, multiple observations over several days revealed that the resident was not wearing the prescribed splints; instead, the splints were found on the bedside table or in the closet, and the resident was observed lying in bed without the splints in place. Interviews with staff indicated confusion regarding responsibility for applying the splints, with some staff believing therapy was responsible and others unaware of the restorative program requirements. The restorative program had not been properly communicated or implemented, resulting in the care plan not being followed. Another resident, with diagnoses including idiopathic epilepsy, dysphagia, and profound intellectual disabilities, had a care plan specifying no chips and supervision with all oral intake. Despite this, the resident was observed self-propelling throughout the facility while eating a bag of potato chips unsupervised on two occasions. Staff interviews revealed an expectation that care plans were reviewed in meetings and that interventions were included in the Resident Care Profile for nursing assistants, but the care plan interventions were not consistently implemented in practice. The facility's policy required individualized, comprehensive care plans with measurable objectives and timetables, to be reviewed and updated as needed. Despite these requirements, the care plans for both residents were not effectively implemented, as evidenced by direct observations and staff interviews. This failure resulted in the residents not receiving care as outlined in their respective care plans.