Failure to Develop Comprehensive Person-Centered ADL Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with individualized interventions for a resident with significant ADL (Activities of Daily Living) needs. The resident, admitted with diagnoses including Alzheimer's disease, COPD, and type 2 diabetes, was assessed as having severe cognitive impairment and required varying levels of assistance for oral hygiene, eating, toileting, dressing, personal hygiene, and was dependent for bathing. Observations showed staff assisting the resident with meal preparation but the care plan and Kardex did not specify the required level of assistance for eating. Interviews with staff confirmed reliance on the Kardex for guidance and acknowledged the resident's dependence on staff for multiple ADLs. Review of the resident's clinical record revealed a care plan that lacked specific, person-centered interventions for all ADL needs, only noting general deficits and some preferences. The care plan did not detail the level of assistance required for each ADL, such as eating, despite the resident's documented needs. Staff interviews further confirmed that the care plan was insufficiently detailed to inform staff of the resident's specific care requirements.