Failure to Implement and Develop Person-Centered Care Plans for Smoking Safety and Pica Behaviors
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, resulting in deficiencies related to smoking safety and management of pica behaviors. For one resident with chronic respiratory failure, COPD, diabetes, and moderate cognitive impairment, the care plan specified that cigarettes and lighters should be kept at the nurses' station and only provided upon request in designated smoking areas. However, observations and interviews revealed that the resident regularly kept a pack of cigarettes and a lighter in her wheelchair pouch, contrary to the care plan and facility policy. Staff confirmed that smoking supplies were not being stored as required. Another resident with severe cognitive impairment, dementia, and a history of eating non-food items was not timely care planned for this behavior. Progress notes documented multiple incidents where the resident chewed or ingested non-food items such as straws, plastics, paper, and cloth. During an observation, the resident was found chewing on string-like material and holding a bib with holes, with staff needing to remove pieces of cloth and food from her mouth. Despite these documented behaviors, the care plan did not initially address the risk of eating non-food items, and staff confirmed the absence of a relevant care plan focus during the review period. These deficiencies were identified through record review, staff and resident interviews, and direct observation, demonstrating a lack of adherence to established care plans and failure to timely address known behavioral risks for the affected residents.