Failure to Implement Comprehensive, Person-Centered Care Plans and Interventions
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans that addressed residents' specific preferences and needs, as documented in their advance directives and clinical records. Several residents had clearly stated wishes to decline certain treatments, such as oral suctioning and oxygen, particularly in end-of-life care situations. Despite these documented preferences, the care plans for these residents did not include interventions reflecting their choices. For example, multiple residents with advance directives explicitly refusing oral suction and oxygen did not have these preferences incorporated into their care plans, even though their cognitive status and ability to participate in care planning varied from severely impaired to cognitively intact. In addition to failures in care planning related to advance directives, the facility did not ensure that specific safety interventions were implemented as outlined in residents' care plans. One resident, identified as high risk for falls, had an intervention for Dycem (a non-slip material) to be used in their wheelchair, but repeated observations showed the Dycem was not present. Staff were unaware of the missing intervention and speculated that the resident may have been removing it, but no alternative intervention was documented or implemented at the time of the survey. Another resident, dependent on staff for transfers and requiring a two-person assist with a mechanical lift, experienced a fall during a transfer when only one staff member was present. The care plan clearly stated the need for two staff during mechanical lift transfers, and facility policy reinforced this requirement. The staff member involved admitted to performing the transfer alone due to perceived staffing shortages, which was contradicted by staffing records. These failures demonstrate a lack of adherence to individualized care plans and facility policies, resulting in unmet resident needs and unaddressed safety risks.