Failure to Develop Comprehensive, Person-Centered Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan that addressed the medical, physical, mental, and psychosocial needs of a resident with multiple diagnoses, including dementia, chronic pain, anxiety, and type 2 diabetes. The resident required significant assistance with activities of daily living (ADLs), such as eating, hygiene, dressing, transfers, and was frequently incontinent of urine and bowel. Despite these needs, the resident's comprehensive care plan and resident profile lacked specific approaches or interventions for staff to follow, leaving essential care areas such as incontinence, ADLs, blood glucose management, pain, and anxiety unaddressed in the care plan documentation. Interviews with CNAs revealed that staff relied on the resident profile for care instructions, but were unable to find any approaches for the resident in question. Both the Nursing Home Administrator and Director of Nursing acknowledged the absence of care plan approaches and confirmed that they should have been present. The facility's own policy required that care plans be comprehensive, person-centered, and regularly updated to reflect the resident's needs, but these requirements were not met for this resident.