Failure to Include Resident Preferences and Vision Needs in Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans accurately described the services to be furnished to meet the highest practicable physical, mental, and psychosocial well-being of four residents. Specifically, the care plans did not reflect the residents' preferences and needs regarding bathing and vision care. For three residents with severe cognitive impairment and significant physical limitations, their repeated refusals of showers and preferences for bed baths were not documented in their care plans, despite staff being aware of these preferences and having residents sign shower refusal forms. Interviews with staff confirmed that these residents commonly refused showers, and the process for documenting refusals was inconsistently followed, with some refusal forms missing from the medical records. Additionally, one resident with a history of cataracts and declining vision did not have her vision needs or the need for eye care and surgery reflected in her care plan. Although there were physician orders and ongoing efforts by the social worker to arrange necessary eye appointments and surgery, these needs were not documented in the care plan. Staff interviews revealed a lack of awareness and communication regarding the resident's vision impairment, and the care plan did not include interventions or plans to address her vision needs. The facility's policies required that care plans be person-centered and include measurable objectives and timeframes to meet residents' identified needs. However, the care plans reviewed did not include the residents' preferences for bathing or their vision care requirements, despite these being known to staff and relevant to the residents' well-being. This omission resulted in care plans that did not fully describe the services to be provided, as required by facility policy and regulatory standards.