Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by policy and regulation. For one resident with a history of stroke, hemiplegia, and communication difficulties, the care plan was incomplete and only addressed behavioral issues and medication, despite the resident expressing ongoing challenges with communication and a desire for speech and rehabilitation services. Observations and interviews revealed that staff did not consistently take the time to communicate with the resident, and there was no evidence of therapy referrals or interventions to address her communication needs. Another resident, with multiple diagnoses including cancer, kidney failure, and depression, did not have a comprehensive care plan initiated at all. The Director of Nursing confirmed that the care plan had not been started, citing staffing issues and turnover in the MDS RN position as contributing factors. This lack of a care plan left staff without clear guidance on how to address the resident's needs and preferences. A third resident, who had a wound on the right foot, was not care planned for this condition, despite having physician orders for wound care. The existing care plan only addressed a separate wound on the abdomen and did not include interventions or goals for the foot wound. Staff interviews indicated that incomplete or missing care plans hindered their ability to provide appropriate care and understand residents' backgrounds and needs.