Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement complete care plans addressing all identified needs for two residents. For one resident, the medical record listed diagnoses of Parkinsonism and a history of suicidal ideations, but neither diagnosis was included in the resident's person-centered care plan. The Director of Nursing confirmed these omissions. For another resident, concerns about poor eating and specific food dislikes were raised by the resident's representative. Although the care plan included an intervention to assess food preferences and provide desired food choices, the facility did not have a documented list of the resident's likes and dislikes, and the Director of Nursing acknowledged that this information was not maintained by the facility. These findings were based on record reviews, staff interviews, and resident interviews during the survey process.