Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, as required by policy and regulation. In multiple cases, care plans were either missing, incomplete, or not updated to reflect changes in residents' conditions. For example, one resident at high risk for elopement did not have their electronic monitoring device checks reinstated or documented after returning from a hospital stay, despite a continued high risk assessment. The care plan was not revised to address this change, and there was no evidence of ongoing monitoring as previously required. Another resident developed a new open area on the coccyx, but the care plan was not updated to document this wound or to include specific interventions for its treatment. Although staff provided wound care and interventions such as turning, positioning, and topical treatments, these actions were not reflected in the resident's care plan. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the care plan should have been updated to address the new wound, but this was not done. Additional deficiencies included a resident with an infection on intravenous antibiotics whose care plan did not include any interventions, and a resident with a stage III pressure ulcer whose care plan was delayed and incorrectly documented the ulcer as stage II. Other residents lacked care plans for significant issues such as BiPAP therapy, major depressive disorder, and adjustment to the facility following admission with complex psychosocial needs. These omissions were identified through record review and staff interviews, demonstrating a pattern of incomplete or missing care plans for residents with identified needs.