Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with diagnoses including bipolar disorder, acute respiratory failure, PTSD, anxiety, and type II diabetes, the care plan addressed mood and behavior issues but did not include interventions for the resident's PTSD, despite this diagnosis being present in the medical record. Observations and staff interviews confirmed the resident exhibited behaviors such as yelling, crying, and distress related to past events, and that redirection and spending time with the resident were effective, yet no care plan for PTSD was in place. For another resident with acute respiratory failure, hemiplegia, hemiparesis, and general anxiety disorder, the care plan did not address activities, even though assessments indicated the resident's preferences for reading, music, and being around pets, as well as a tendency to prefer self-directed leisure activities. The Activities Director confirmed that an activities care plan was never developed for this resident following admission. These omissions were identified through medical record review and staff interviews, and were not in accordance with the facility's policy requiring comprehensive, person-centered care plans for all residents.