Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for seven residents, as identified through record review, observation, and staff interviews. For one resident, the care plan did not address individual or group activity preferences, despite the resident expressing strong interests in reading, music, animals, news, favorite activities, and religious services. Staff confirmed the absence of a care plan for these preferences, and the Activities Director acknowledged this omission. Another resident, who required supervised smoking per assessment and facility policy, did not have a care plan addressing supervised smoking, and the Unit Manager confirmed this gap. A resident dependent on a wheelchair for mobility and requiring assistance with eating, hygiene, and transfers did not have a care plan addressing these needs, as confirmed by staff. Another resident with physician orders to offload heels to prevent skin breakdown was repeatedly observed in bed with heels directly on the mattress, and staff were unaware of the care plan intervention or physician order. Additionally, a resident who had smoking privileges revoked did not have a care plan addressing smoking status or the removal of privileges, as confirmed by the Director of Nursing. Further deficiencies included a resident on hemodialysis and multiple medications who required assistance with activities of daily living but only had care plans for code status and nutritional risk, with no interventions for other identified needs. Lastly, a resident whose primary language was Cambodian and who only understood simple English commands did not have a care plan addressing communication barriers, and staff were unaware of the resident's language needs. These findings demonstrate multiple failures to develop and implement care plans that address the comprehensive needs of residents as identified in their assessments.