Failure to Develop and Implement Resident-Centered Care Plans
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive, resident-centered care plans that accurately reflected the assessed needs and preferences of multiple residents. For one resident with expressive aphasia and total dependence on staff for activities of daily living, the care plan did not include specific information about the resident's music preferences, television programs, or religious denomination, despite these being documented as important in assessments. The care plan also lacked documentation of certain activities, such as hand massages, that were reportedly provided. The Activity Director acknowledged that care plans did not always reflect assessment findings and that staff often relied on assumptions rather than resident input. Another resident with a history of traumatic brain injury, anxiety, depression, and cognitive impairment reported not participating in activities due to a lack of interest and was unaware of care planning meetings. The care plan for this resident did not address their stated preferences for religious services and access to reading materials, which were documented as very important in the MDS assessment. Similarly, a resident with a history of stroke and cognitive deficits stated that they used personal devices for entertainment and required assistance to attend activities, but their care plan did not specify their preferences for church attendance or reading materials, despite these being identified during assessments and interviews. Additionally, a resident admitted to the facility had only a baseline care plan documented, with no comprehensive care plan completed within the required timeframe following the comprehensive assessment. There was also a lack of documentation indicating that the interdisciplinary team regularly attended care plan meetings. Staff interviews confirmed these deficiencies, and facility leadership acknowledged the concerns raised by surveyors regarding the lack of individualized, assessment-based care planning.