Deficiencies in Comprehensive Care Planning and Implementation
Penalty
Summary
Facility staff failed to develop and/or revise comprehensive, person-centered care plans to meet the needs of several residents, as identified through observation, staff interviews, clinical record reviews, and facility document reviews. For one resident with a complex mental health history, the care plan did not reflect pertinent diagnoses such as a history of suicide attempt and abuse, nor did it include individualized interventions. Additionally, staff did not consistently follow the care plan regarding the administration of ordered medications for behavioral symptoms, with documentation showing missed or delayed administration of antipsychotic and anxiolytic medications. Another resident's care plan did not accurately reflect the level of assistance required for safe toileting. There was inconsistency between the care plan, staff practices, and family expectations regarding toileting methods, with conflicting documentation about the use of bedpans versus transferring to the toilet. The care conference notes lacked specific documentation of discussions with the family about these concerns, and the care plan did not clearly address the resident's physical limitations and preferences. Additional deficiencies included the failure to address the presence of a peripherally inserted central catheter (PICC) in a resident's care plan, and the failure to implement care plan interventions such as the use of bed bolsters for fall prevention. In another case, a resident's care plan did not correctly identify the purpose of an anticonvulsant medication and included incorrect interventions referencing anti-Parkinson's medications without supporting diagnoses. These deficiencies were identified during surveyor observations, interviews, and record reviews, and were discussed with facility leadership during exit conferences.