Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement complete, person-centered care plans to address the medical, nursing, mental, and psychosocial needs of several residents. One resident expressed a desire for dental extractions and was evaluated by a prosthodontist, who recommended full mouth rehabilitation and surgical extractions. Despite this, the resident's care plan did not address their dental issues, and there was no evidence of a care plan to meet these needs. Another resident was admitted to hospice care, but their care plan was not updated to reflect their hospice status, as confirmed by staff and medical record review. For residents assessed as high risk for elopement or wandering, the facility did not consistently include appropriate interventions in their care plans. One resident with a high elopement risk and a physician order for a Wander Guard device did not have a care plan focus for wandering or exit-seeking behaviors. Another resident's care plan was not updated to reflect changes in monitoring orders for their wander prevention band, despite documentation of behavioral monitoring and device checks in the medical record. Additionally, a resident with ataxia and muscle weakness, who was identified as requiring supervision and a smoking apron/blanket while smoking, was repeatedly observed smoking without supervision and without the required protective equipment. The care plan for this resident did not include the need for a smoking apron/blanket, as indicated in the smoking safety screen. Staff interviews confirmed that residents were non-compliant with the smoking policy, and the care plan did not fully address the resident's safety needs during smoking activities.