Failure to Develop and Implement Comprehensive Care Plans for ADL and Dementia Needs
Penalty
Summary
Surveyors identified deficiencies related to the development and implementation of comprehensive, person-centered care plans for multiple residents. Several residents with ADL self-care deficits, cognitive impairments, or dementia did not have care plans that addressed all their needs, or the existing care plans were not followed. For example, one resident with a diagnosis of dementia did not have a dementia care plan developed after the diagnosis was added, which was confirmed by both the MDS Coordinator and Social Services. Other residents with ADL deficits, such as those requiring assistance with bathing, personal hygiene, and nail care, were observed to have unmet hygiene needs, including long and dirty fingernails, unshaven facial hair, and infrequent bathing, despite care plans indicating the need for regular assistance. Direct observations and interviews revealed that some residents expressed dissatisfaction with their hygiene and grooming, stating they wanted their nails trimmed or to be clean-shaven, and that they had not received showers or baths as scheduled. In several cases, staff interviews confirmed that residents had not received care as outlined in their care plans, and documentation of care refusals was lacking or absent. For instance, one resident had not received a bath or nail care since admission, and there was no documentation of refusals, despite staff stating the resident refused care. Another resident, who was cognitively intact, had long, jagged fingernails and stated he wanted them cut, but there was no evidence of recent nail care. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. However, the survey found that care plans were either not developed for certain conditions, such as dementia, or not implemented as written for residents dependent on staff for ADLs. Staff interviews confirmed that failure to follow care plans resulted in residents not receiving the care they deserved, and that care plans are essential for guiding staff in providing necessary care.