Failure to Develop and Implement Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents, as identified during a recertification survey. For one resident with significant cognitive impairment and limited mobility, the care plan did not specify the individual's preferred independent activities, nor did it address important preferences such as pet visits and going outside for fresh air, despite these being documented as very important in the Minimum Data Set (MDS) assessment. Additionally, the care plan for pressure ulcer prevention referenced the use of a bariatric air mattress and required checks for placement and function every shift, but there was no current physician order for the mattress, and documentation of these checks was missing after a certain date. The air mattress was also found to be set incorrectly, and staff were unclear about the correct settings and responsibilities for monitoring the equipment. For another resident, the activity care plan was not individualized to include the resident's preferences for going outside and participating in religious services, as indicated in the MDS assessment. The care plan only mentioned watching TV as an independent activity, omitting other significant preferences. The activities director confirmed that these preferences were not addressed in the care plan. Additionally, this same resident was admitted with pitting edema in both legs, and ongoing provider notes documented continued edema. However, the care plan did not address the resident's edema, despite staff and the director of nursing acknowledging the presence of this condition since admission. These omissions demonstrate a lack of comprehensive and individualized care planning based on residents' assessed needs and preferences.