Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by policy. For one resident with dementia, diabetes, depression, and anxiety, the care plan did not address their ongoing use of chewing tobacco, despite documentation in their social history and direct observation of tobacco use at the bedside. Staff interviews confirmed that tobacco use was not identified or addressed in the care plan for this resident. Another resident with metabolic encephalopathy, joint replacement aftercare, and dementia had no care plan areas identified for their diagnoses, medications, nutrition, pain, fall risk, or mood and behavior, despite requiring substantial assistance and having severely impaired cognition. A third resident, admitted with a stomach wound, asthma, PTSD, and heart complications, had a positive trauma history but no care plan development regarding PTSD or their traumatic experiences. Staff interviews confirmed that care plans were expected to be comprehensive and individualized, but these requirements were not met for the residents reviewed.