Lack of Care Planning and Documentation for Room Modifications
Penalty
Summary
A deficiency was identified when a resident's room was found to be devoid of home-like touches and furniture, with the mattress placed directly on the floor and no decorations or personal items present. The resident, who had diagnoses of type 2 diabetes mellitus, dementia, and schizoaffective disorder, was assessed as severely cognitively impaired but able to communicate. Observations confirmed the lack of furniture and home-like environment, and documentation review revealed no physician order or care plan supporting the removal of the bed frame, furniture, or the placement of the mattress on the floor. Interviews with facility staff indicated that the furniture and bed frame had been removed due to the resident's behaviors and safety concerns, such as attempts to take apart the bed frame. However, staff were unaware of any care plan or physician order authorizing these changes, and the care plan did not reflect the current room setup. The lack of documentation and care planning for these significant environmental modifications resulted in the resident not receiving care and services in accordance with their preferences, choices, values, and beliefs.