Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement accurate, person-centered comprehensive care plans for four residents. For two residents with dementia and other behavioral or mood disorders, the care plans did not include their personal preferences for activities, such as pet visits, group activities, going outdoors, and religious services, as identified in their MDS Annual Assessments. The Activity Director confirmed that these preferences, although assessed, were not incorporated into the residents' care plans. Additionally, one resident with a primary diagnosis of hypertensive urgency did not have a care plan addressing this condition, and another resident with adrenocortical insufficiency lacked a care plan for this diagnosis as well as for the level of assistance required for showering or bathing, as indicated in the MDS assessment. The corporate nurse confirmed the absence of these care plans. These omissions were identified through record reviews and staff interviews.