Failure to Develop Person-Centered Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for several residents with specific care needs. For one resident with a Foley catheter, the care plan did not specify the type of catheter, its size, or detailed interventions for catheter care, such as monitoring for pain, discomfort, or placement. The care plan used non-specific language and was not revised to reflect the resident's actual needs, despite facility policy requiring individualized care plans based on daily monitoring and assessment for complications. Two residents who were candidates for bowel and bladder retraining did not have individualized, measurable objectives or specific interventions documented in their care plans. Their care plans lacked resident-specific goals or preferences and did not include interventions such as scheduled toileting or timed voiding, even though assessments indicated these were appropriate. The interventions listed were generic, such as assisting with toileting as needed and providing pericare, without addressing the potential to maintain or restore continence. Another resident with chronic pain did not have all pain management interventions, particularly non-pharmacological methods, included in the care plan. Although physician orders and staff interviews indicated the use of both medication and non-medication interventions for pain, the care plan did not reflect these non-pharmacological strategies. Facility policy required that all interventions used to manage a resident's pain be documented in the care plan, but this was not done, resulting in incomplete care planning for pain management.