Failure to Implement Resident Care Plan Intervention
Penalty
Summary
A deficiency was identified when a resident with a history of bipolar disorder, dementia, and anxiety disorder was observed on multiple occasions without a properly implemented intervention as outlined in their care plan. The resident's care plan included the use of a mesh stop sign across the door to prevent other residents from wandering into the room, an intervention initiated due to the resident's physical and verbal behaviors directed towards others as documented in the Minimum Data Set (MDS). However, during facility tours, the surveyor observed that the stop sign was not connected to both sides of the door as required. Interviews with facility staff confirmed that the care plan specified the use of the stop sign and that it was not being followed when the stop sign was not in place. The Unit Manager LPN acknowledged that the care plan was not being adhered to in these instances, and the DON affirmed that staff are expected to follow residents' care plans. The facility's policy also requires the interdisciplinary team to develop and maintain care plans in coordination with the resident and their family.