Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs. The resident in question had multiple complex diagnoses, including encephalopathy, type 2 diabetes, aphasia, generalized anxiety disorder, chronic pain syndrome, cerebral infarction, dysphagia, hemiplegia, and major depressive disorder. The care plans on record addressed some needs, such as functional deficits, incontinence, and neurological status, but did not include interventions for several specific issues. Notably, there was no care plan or intervention for the resident's repeated refusals of incontinence care, sensitivity to light during nighttime care, preference for certain staff, or desire to sleep through scheduled care times. Additionally, an intervention for a bowel and bladder program was listed, but the resident was never actually on such a program. Interviews with staff and the resident revealed ongoing issues that were not addressed in the care plan. The resident frequently refused incontinence care, especially at night, citing discomfort and a dislike of being woken up or having lights turned on. The resident also expressed a preference for certain caregivers and would refuse care from others, particularly male staff. Staff confirmed these refusals and noted that documentation of refusals was done under behavior monitoring, but these behaviors were not specifically addressed in the care plan. The Director of Nursing acknowledged that interventions for these specific refusals and preferences were not included in the care plan. Additionally, the resident had concerns about the use and fit of her wheelchair, expressing fear of falling and discomfort with the equipment provided. Occupational therapy notes indicated ongoing assessment and modification of the wheelchair, but interviews with staff revealed uncertainty about whether the wheelchair fit properly or was appropriate for the resident's needs. There was no care plan in place to address the resident's fear of using the wheelchair or her reluctance to get out of bed, despite these being ongoing issues. This lack of comprehensive, individualized planning resulted in the resident's needs and preferences not being fully addressed.