Failure to Develop and Implement Comprehensive Resident Care Plans
Penalty
Summary
Facility staff failed to develop and implement comprehensive, resident-centered care plans for multiple residents, as evidenced by three specific cases. In one instance, a resident with no cognitive impairment but significant physical limitations was able to leave the facility premises without staff knowledge, ultimately being found at a nearby shopping center parking lot. Despite a prior physician's order requiring supervision for leave of absence and an MDS assessment indicating the resident was wheelchair-bound, the facility did not recognize the incident as an elopement, did not update the elopement risk assessment appropriately, and failed to create a care plan or interventions to prevent recurrence. Both the DON and NHA acknowledged not recognizing the event as an elopement. In another case, a resident was discharged from the facility without a discharge care plan, and the responsible social worker could not provide a rationale for this omission. Additionally, a third resident, who was frequently incontinent of bowel and bladder according to MDS assessments and a bowel elimination pattern document, had no care plan addressing incontinence, despite complaints of malodor and lack of ADL care. The DON confirmed the absence of an incontinence care plan for this resident. These findings demonstrate a pattern of failure to develop and implement individualized care plans based on residents' assessed needs.