Failure to Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, resulting in unmet needs. For one resident, who was cognitively intact and dependent on staff for bathing due to a cerebrovascular accident, there was no documentation of his stated preference for a daily bed bath. Although the resident and several CNAs confirmed his preference, this information was not reflected in his care plan, ADL flowsheet, or CNA assignment sheet. Staff who were not regularly assigned to him were unaware of his preference, as it was not documented anywhere accessible to them. For another resident with severe cognitive impairment and total dependence on staff for self-care, the care plan and physician's orders required a soft mitt or splint to be in place on her right hand at all times to prevent her from pulling on medical tubing. Multiple observations throughout the day revealed that neither the soft mitt nor the splint was in place on her right hand. Staff interviews confirmed that the resident should have had one of these devices in place at all times, as per the physician's orders and care plan, but this was not being followed. These deficiencies were identified through observations, interviews, and record reviews, and were found to be inconsistent with the facility's own care planning policy, which requires care plans to be based on resident assessments, goals, and preferences, and to be implemented in accordance with physician orders.