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 two residents, resulting in unmet needs related to medical appointments and skin care. For one resident, the medical record showed multiple physician orders for dental, cardiology, neurosurgery, and neurology consults, but there was no evidence that these appointments were attended. The resident often scheduled and canceled appointments independently, and staff did not maintain documentation of when or where the resident went for these appointments. Interviews with the Administrator and Transportation/Scheduler confirmed that the facility was not consistently involved in arranging or tracking the resident's outside medical visits, and the care plan did not address the resident's preferences or behaviors regarding appointment scheduling and attendance. Another resident experienced a recurrent rash on the lower legs, with documentation of ongoing symptoms and repeated courses of topical treatment. The resident was seen by both dermatology and rheumatology, and follow-up appointments were ordered, but the care plan addressing skin integrity was generic and not tailored to the resident's persistent and recurring condition. The care plan lacked specific, measurable actions or approaches to address the ongoing rash, despite repeated documentation of the issue and multiple specialist referrals. In both cases, the facility's care planning process did not adequately address the residents' individual needs, preferences, or the complexity of their medical situations. The deficiencies were identified through medical record review and staff interviews, which revealed gaps in documentation, lack of comprehensive planning, and insufficient coordination of care for residents with ongoing or complex health concerns.