Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for several residents, specifically in the areas of activities, depression, and post-traumatic stress disorder (PTSD). For multiple residents, care plans lacked personalization, with interventions and goals that were generic and did not reflect the residents' specific interests or diagnoses. For example, several residents had care plans that did not specify which activities they enjoyed, despite assessments or staff knowledge indicating clear preferences such as crafts, music, gardening, or social activities. In some cases, activity assessments were missing entirely, and scheduled one-to-one visits were not provided as documented in the care plans. Residents with mental health diagnoses, including depression and PTSD, were not adequately addressed in their care plans. For instance, one resident with documented PTSD and depression had a care plan that only addressed anxiety, omitting the other diagnoses. Another resident's care plan did not mention PTSD at all, despite the diagnosis being present in the medical record. Staff interviews confirmed that these omissions were not due to a lack of awareness but rather a lack of interdisciplinary collaboration and communication during care plan development. The process for creating and updating care plans was found to be insufficiently interdisciplinary. The Activities Director reported not being invited to care plan meetings and not being responsible for writing care plans, while the Social Worker stated that care plans were typically developed by reviewing medical records without input from other departments or the residents themselves. There was also a lack of documentation regarding care plan meeting attendance and resident or representative involvement. Additionally, pain management care plans lacked measurable objectives, timeframes, and individualized details, and there was no evidence of ongoing evaluation or interdisciplinary discussion regarding pain management, even when residents reported pain that interfered with daily function.