Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents with significant care needs. One resident, admitted with hemiplegia, type 2 diabetes mellitus, and morbid obesity, was documented as being dependent on staff for personal hygiene. Observations revealed the resident was unshaven with long, unkempt facial hair and fingernails that were long, curling, and had brown debris underneath. Staff interviews confirmed that the resident frequently refused ADL care, and this issue had been reported to administration. However, a review of the resident's care plan showed that these refusals and the need to address them were not included in the care plan. Another resident, also with hemiplegia and type 2 diabetes mellitus, required substantial to maximal assistance for personal hygiene. Observation showed this resident had long, curling fingernails. The report documents that the care plans for both residents did not address their specific needs related to personal hygiene and refusals of care, as identified through record reviews, staff interviews, and direct observation.