Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans for multiple residents, as evidenced by surveyor observations, medical record reviews, and interviews. For one resident who is legally blind, the care plan did not address their stated preferences for accessible reading materials, music, religious services, or being around pets, despite these being identified as important in the Minimum Data Set (MDS) assessment. The care plan also failed to account for the resident's need for assistance with reading activity calendars due to their visual impairment. Another resident admitted for rehabilitation services reported being unaware of available activities and only occasionally encountering them by chance. Review of this resident's care plan revealed that no activities care plan was in place, and staff confirmed that required MDS sections had not been completed or implemented into the care plan. A third long-term resident expressed a desire for more varied activities, stating that only bingo was offered, which did not align with their preferences documented in the MDS for reading materials and outdoor time. The care plan for this resident only included group activities like bingo, failing to match the resident's stated interests. A fourth resident with severe dysphagia and a history of stroke was observed eating unsupervised on multiple occasions, despite care plan directives for aspiration precautions, one-person assistance, and supervision during meals. The resident was also observed eating in bed, contrary to care plan instructions to be out of bed for meals, and refusals of care were not documented as required. Staff interviews confirmed confusion regarding supervision expectations and inconsistencies between care plan documentation and observed practices.