Failure to Develop and Update Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and update comprehensive, person-centered care plans for two residents, as required by policy and regulation. For one resident with a history of cerebrovascular disease, hypothyroidism, and aphasia, clinical records and therapy notes indicated the presence of hand contractures and the need for bilateral palm guards with specific instructions. Despite these documented needs and the resident's inability to reach the call light or hand bell due to contractures, the care plan only included a generic instruction to keep the call light in reach, without addressing the resident's physical limitations or providing alternative alert methods. For another resident diagnosed with Alzheimer's disease, cerebrovascular disease, and dysphagia, a provider's order required the resident to be out of bed for all meals. This instruction was posted on the nursing unit communication board, but the resident's care plan did not include this requirement. The Director of Nursing confirmed that care plans for both residents lacked necessary instructions to provide individualized, person-centered care as indicated by their current conditions and provider orders.