Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents as required by policy and federal regulations. For one resident with diabetes, dysphagia, hyperlipidemia, and vocal cord paralysis, there was a communication deficit requiring the use of an electronic device. This resident reported not receiving regular showers as scheduled, stating it had been two weeks or more since the last shower. Although the Assistant Director of Nursing stated the resident had refused a recent shower, a review of nursing notes and documentation showed no record of refusals, and the care plan did not address shower refusals or related issues. For another resident with dysphagia, cognitive communication deficit, and hyperosmolality/hypernatremia, there was a physician order for NPO (nothing by mouth) status. Despite repeated observations and documentation of the resident being non-compliant with NPO status by consuming ice and water, the care plan did not include any focus area or interventions addressing this non-compliance. Nursing notes documented education and monitoring, but the care plan was not updated to reflect the resident's behavior. These findings were confirmed by facility staff.