Failure to Develop and Implement Individualized Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for two residents, one with dementia and one with a urinary catheter. For the resident with dementia, the care plan noted severe cognitive impairment, depression, and anxiety, and included interventions such as asking yes/no questions, cueing, and monitoring cognitive changes. A separate care plan addressed the resident's primary language, Dutch, and called for the use of Dutch-to-English signage provided by the family. However, during observation, no such signage was present in the resident's room, and staff were unaware of this intervention, indicating the care plan was not fully implemented. For the resident with a urinary catheter, the care plan documented the presence of the catheter but did not specify the clinical reason for its use, whether it was unavoidable, or the required follow-up care. Interviews with staff revealed a lack of awareness regarding the rationale for the catheter and acknowledged that the care plan was vague and incomplete. The absence of individualized and comprehensive care planning for both residents was confirmed through observation, interviews, and record review.