Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for multiple residents, resulting in unmet needs and noncompliance with physician orders and facility policies. For one resident with quadriplegia, seizures, and a PEG tube, staff did not ensure the bed alarm was properly placed, connected, or functioning as ordered. Observations over several days showed the bed alarm control box was detached and not connected, with the alarm mat misplaced in a Geri chair rather than on the bed. The resident was unable to locate her call light and reported a history of falls, while staff confirmed the bed alarm was not in use as required by the physician's order. Another resident who smoked cigarettes was not care planned for smoking, despite a completed Smoking Evaluation Tool and facility policy requiring individualized care plans for smokers. The resident's care plan did not address smoking, and the LPN responsible for care plans acknowledged this omission during review. Facility policy specifies that all smokers must have a care plan based on their evaluation, but this was not implemented for the resident in question. A third resident with multiple complex diagnoses, including schizophrenia, anxiety disorder, and chronic liver disease, had only a single, generalized care plan area focused on disease management. The care plan lacked comprehensive, person-centered interventions and did not address the resident's full range of needs, strengths, preferences, or goals. The LPN responsible for care plans confirmed that a comprehensive care plan had not been developed or implemented in a timely manner for this resident.