Failure to Implement Individualized Care Plans for Multiple Residents
Penalty
Summary
Multiple residents experienced deficiencies in care due to the facility's failure to implement individualized, comprehensive care plans as documented. One resident with a history of traumatic brain injury and moderate cognitive impairment required total assistance with eating, but was left unattended with her meal tray for 30 minutes without staff assistance. Another resident, who was cognitively intact and had diagnoses including intellectual disabilities and schizophrenia, was observed with excessively long and thick toenails, despite a care plan intervention for nail care. Staff interviews confirmed that the care plans for these residents were not followed. A resident with a diagnosis of PTSD and a history of military service and trauma had an inaccurately completed trauma assessment, which failed to identify his symptoms and triggers, such as distress caused by helicopters. This led to the care plan not addressing his specific psychosocial needs. Additional deficiencies were observed in residents requiring assistance with oral hygiene and personal care. One resident with hemiplegia and moderate cognitive impairment had visible dental buildup and reported infrequent mouth care, while another dependent resident had long, dirty fingernails and facial hair, indicating a lack of daily hygiene assistance as outlined in their care plans. Further, a resident at risk for falls due to impaired mobility was found without required safety interventions, such as a bedside fall mat and a wedge cushion, despite these being specified in the care plan. Staff interviews and record reviews consistently confirmed that while care plans were fully developed and individualized, they were not implemented by staff, resulting in unmet physical, psychosocial, and functional needs for several residents.