Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans with measurable objectives and timeframes for two residents, as identified through observation, interview, and record review. For one resident with dementia, muscle weakness, dysphagia, anxiety disorder, and bipolar disorder, the care plan inaccurately documented the presence of a feeding tube and did not address the resident's need for substantial or maximal assistance with eating. Observations showed the resident was unable to feed himself, with his spoon out of reach and food spilled, requiring a CNA to feed him. Staff interviews revealed confusion about the resident's actual needs and the care plan's accuracy, with some staff believing he only needed set-up assistance and others acknowledging he required direct feeding assistance at times. The care plan for this resident was not updated to reflect his fluctuating ability to eat independently and his behavioral issues, such as spitting and refusing assistance. Staff interviews indicated that although CNAs often provided feeding assistance, the care plan did not specify this need, and there was a lack of clarity and communication among staff regarding the resident's actual requirements. The documentation error regarding a feeding tube further contributed to the lack of appropriate interventions in the care plan. For another resident with nicotine dependence and COPD, the care plan did not include any interventions related to smoking, despite the resident being on the facility's smoking list and self-reporting as a smoker. Staff interviews confirmed that the omission was due to a lack of communication and oversight, and the care plan was not updated to address the resident's smoking needs. Facility policy required that such needs be care planned, but this was not done, resulting in the resident's smoking status and related care needs not being addressed in the care plan.