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 complex medical and psychosocial needs. Specifically, care plans for residents with diagnoses such as dementia, depression, diabetes, and neurocognitive disorders did not include individualized instructions or measurable goals and timetables as required by facility policy and regulatory standards. For example, residents with dementia or related symptoms did not have care plans addressing appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Additionally, a resident with ongoing psychotherapy for anxiety and depression did not have a care plan addressing their psychosocial concerns or monitoring for depressive symptoms, despite multiple psychiatry visits and recommendations. Another resident receiving insulin for diabetes lacked a care plan that included the use of insulin and protocols for managing hyperglycemia and hypoglycemia, even though physician orders and medication administration records indicated ongoing insulin therapy. Furthermore, a resident with a neurocognitive disorder and behavioral issues did not have a care plan addressing their cognitive decline, behavioral symptoms, or interventions to manage these behaviors. These deficiencies were confirmed through staff interviews and review of clinical records, demonstrating a pattern of incomplete or missing care plans for residents with significant medical and behavioral needs.