Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with significant care needs. For one resident who was re-admitted with a history of a displaced intertrochanteric fracture of the left femur, documentation showed that the resident experienced a fall resulting in a hip fracture and required hospitalization and surgery. However, review of the resident's care plan did not show any evidence that the actual fall with injury was addressed or incorporated into the care plan, and the Director of Nursing Services was unable to provide documentation of a comprehensive care plan related to this incident. For another resident with diagnoses including a left patella fracture, hip pain, and dementia, the care plan contained conflicting instructions regarding transfer methods. The plan indicated the use of a mechanical lift requiring two staff for transfers, but also referenced the use of a slide board for transfers. Further documentation confirmed the resident was dependent for all transfers, yet the care plan did not specify a single, consistent transfer device. The Director of Nursing Services acknowledged the inconsistency and was unable to provide evidence of a comprehensive, person-centered care plan that accurately reflected the resident's transfer needs.