Failure to Develop Comprehensive and Accurate Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the needs and status of two residents. For one resident with impaired cognitive function and a history of dementia, the care plan incorrectly documented the resident's cognitive status by stating a BIMS score greater than 12, when in fact all assessments consistently showed a BIMS score of 3, indicating severe cognitive impairment. This error was confirmed by the Director of Nursing, who acknowledged that the resident had never had a BIMS score of 12 during their stay, and that the care plan was inaccurate from its initial development and subsequent revision. For another resident, repeated observations during mealtimes showed the individual feeding himself with his hands, dropping food on his clothes and the floor, and having difficulty using utensils. Staff interviews confirmed that the resident required constant supervision and cueing to use utensils, and that he performed well with one-on-one assistance. However, the care plan only indicated that the resident required set-up assistance with eating, without addressing the need for ongoing supervision and cueing. This discrepancy between the resident's observed needs and the documented care plan was confirmed by both nurse aides and the speech therapist.