Failure to Implement and Document Person-Centered Care Plans
Penalty
Summary
Staff failed to follow the care plan for a resident with a history of falls, muscle weakness, cognitive communication deficit, traumatic brain injury, and metabolic encephalopathy. The resident's care plan required a fall mat to be placed next to the bed due to previous falls with injury. However, during two separate observations, the resident was found in bed without a fall mat present. Interviews with a CNA and an LPN confirmed the absence of the fall mat, and the LPN acknowledged that the care plan did require it. The DON also confirmed that the fall mat should have been in place according to the care plan and that staff are expected to ensure this intervention is implemented. Another resident with a diagnosis of dementia was admitted to the facility, but the care plan did not document the dementia diagnosis or any interventions to address it. The care plan lacked information on maintaining the resident's highest practicable well-being related to dementia. The DON confirmed that the resident's dementia diagnosis and related interventions were not included in the care plan and stated that this information should be documented to provide appropriate care for memory and health maintenance.