Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to fully develop, revise, and implement person-centered comprehensive care plans for two residents. For one resident with dementia and diabetes, who was severely cognitively impaired and primarily Spanish-speaking, the care plan did not include interventions for effective communication, despite staff acknowledging the need for Spanish-speaking support or an interpreter. Additionally, after the resident experienced a fall and was identified as high risk for both falls and elopement, the care plan was not updated to reflect new treatment goals or interventions for fall prevention or wandering risk. For another resident with cerebral palsy, quadriplegia, and significant mobility deficits, the care plan specified the need for two staff members to assist with repositioning and turning in bed. However, this intervention was not reflected in the Kardex system used by nurse aides, and there was no documentation that direct care staff were informed of the requirement for two caregivers for safe bed mobility. The Nursing Home Administrator was unable to provide evidence that these care plan interventions were communicated to staff, resulting in a lack of implementation of the resident's individualized care needs.