Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents with specific medical needs, as required by facility policy and regulatory standards. For residents with COPD and physician orders for continuous oxygen therapy, there was no individualized respiratory care plan or documentation addressing their oxygen use, despite clinical records and direct observations confirming their ongoing oxygen therapy. Interviews with nursing staff confirmed the absence of these required care plans. Additionally, residents with mental health diagnoses such as depression, anxiety, and dementia did not have care plans or interventions documented to address these conditions. Clinical records and care plan reviews showed that residents with new or existing diagnoses of depression, anxiety, and dementia were not provided with individualized care plans or interventions tailored to their needs, as required by the facility's interdisciplinary care planning protocol. The deficiency was identified through a combination of clinical record reviews, staff and resident interviews, and direct observation of residents receiving care. The findings demonstrated that the facility did not follow its own policies for timely and specific care planning, resulting in the lack of comprehensive care plans for residents with COPD, oxygen therapy needs, depression, anxiety, and dementia.