Care Plan Lacked Person-Centered Interventions for Resident with Right-Sided Deficit
Penalty
Summary
The facility failed to revise the comprehensive care plan to reflect the specific personal care needs of a resident with significant medical and cognitive impairments. The resident, who had a history of cerebral vascular accident with right-sided hemiplegia, dysphagia, aphasia, depression, cognitive communication deficit, and epilepsy, was assessed as having severe cognitive impairment. Multiple staff interviews revealed that the resident required specialized care techniques during activities of daily living, such as providing step-by-step explanations, working slowly and gently, offering breaks, and monitoring for signs of frustration or pain, particularly with right arm movement. Staff consistently described the need for these individualized approaches due to the resident's right-sided weakness, pain, and tendency to become anxious or frustrated during care. Despite these identified needs, the resident's care plan did not include detailed, person-centered interventions specific to the resident's care requirements. The care plan noted a right-sided deficit and a general intervention to explain activities prior to starting them, but it lacked instructions for providing care slowly and gently, offering breaks, and monitoring for increased frustration. Staff were unable to identify documentation of these specific actions in the care plan, and the plan did not fully address the specialized techniques necessary for the resident's safe and comfortable care.