Failure to Develop and Implement Comprehensive Care Plans for At-Risk Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for residents with identified risks and needs. Specifically, two residents with severe cognitive impairment and documented risk for elopement did not have care plans addressing their elopement risk upon admission, as confirmed by both record review and interviews with the Director of Nursing. Additionally, a resident with paraplegia and bilateral hand contractures did not have an active care plan to address her contractures, despite observations of her condition and her reports of inconsistent interventions such as the use of wash cloths and braces. Interviews with facility staff, including the Director of Nursing and Therapy Director, confirmed the absence of required care plans for these residents. The lack of documented, measurable objectives and timeframes to address the residents' medical, nursing, and psychosocial needs was evident in the records and through staff acknowledgment, indicating a failure to meet regulatory requirements for comprehensive care planning based on the residents' assessments.