Failure to Ensure Person-Centered Care Plans Addressed All Resident Needs
Penalty
Summary
The facility failed to ensure that person-centered care plans were completed to address all aspects of care, including individualized goals and approaches for eating and assistance with turning and repositioning, for two residents. For one resident with a history of stroke, hemiparesis, and aphasia, the care plan included an intervention to encourage frequent repositioning for pressure relief. However, the DON acknowledged that this resident could not perform this action independently, indicating the care plan did not accurately reflect the resident's needs or abilities. Another resident with dysphagia and a history of stroke required a mechanically altered diet and specific adaptive equipment for eating and drinking. Observations revealed that instructions for care, such as the use of a knobbed cup, prohibition of straws, and a preferred schedule for getting out of bed, were posted in the resident's room but were not included in the care plan or the Kardex, which nursing assistants use to guide care. Staff confirmed that these directives were missing from the official care documentation, resulting in a lack of consistent and comprehensive guidance for staff providing care.