Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and/or implement comprehensive care plans for six residents, resulting in unmet needs across multiple domains. For one resident with severe cognitive impairment and incontinence, documentation showed repeated failures to provide and record toileting assistance as required by the care plan over several months. Staff interviews confirmed that toileting assistance should have been provided and documented, but records did not support consistent implementation. Another resident, also with severe cognitive impairment, did not receive structured activities as outlined in their care plan. Staff and administrative interviews revealed that for months, there were no regular activities in the memory care unit due to staffing challenges, and the facility could not provide evidence of activity participation for the resident during that period. Additional deficiencies included the lack of a care plan addressing the needs of a resident on the memory care unit, despite documentation of severe cognitive impairment. For another resident with brain cancer and a seizure disorder, the care plan failed to address critical aspects such as radiation therapy, chemotherapy, anticonvulsant use, and the cancer diagnosis, even though these treatments and diagnoses were documented in the medical record. The regional MDS coordinator confirmed that these omissions meant the care plan was not comprehensive for the resident's needs. Further, the facility did not implement one-on-one monitoring for a resident with behavioral issues as required by the care plan, with no documentation to show monitoring occurred on multiple dates or that it was discontinued. In another case, a resident with quadriplegia and total dependence for personal hygiene had no documentation of care provided or refusal of care on a specific date, despite the care plan requiring total staff assistance. Staff interviews confirmed that care plans are intended to be individualized and updated as needed, but the required interventions were not consistently documented or implemented.