Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and/or implement person-centered care plans for eight of 35 sampled residents, resulting in deficiencies related to individualized care. For one resident with limited right arm mobility and pain, the care plan included interventions such as elevating the right arm on a pillow and monitoring for skin changes, including discoloration. However, observations and interviews revealed that these interventions were not consistently implemented, as staff did not regularly elevate the arm or monitor for skin changes, leading to the development of a bruise that went unnoticed by staff until later. The care plan was not followed as required, and staff were unaware of the skin issues until they were pointed out during the survey. Another resident with hemiplegia and contractures had physician orders and therapy recommendations for the application of a left hand roll and both elbow extension splints, as well as passive range of motion (PROM) to both arms and legs. While the care plan addressed PROM and splints for the legs, it did not include the necessary interventions for the arms as recommended by therapy and ordered by the physician. Staff interviews confirmed that the omission of these interventions from the care plan was an oversight, and the care plan was not updated to reflect the resident's full needs. Additional deficiencies were identified for residents who were prescribed antibiotics or anticoagulants, as well as those using physical restraints such as beds with bolsters or concave mattresses. In these cases, care plans were either not developed or not updated in a timely manner to address the use of these medications or devices, as required by facility policy. Staff interviews and record reviews confirmed that the absence or delay in care plan development could result in a lack of appropriate monitoring and interventions for these residents. Facility policies required timely and comprehensive care planning, but these were not followed for the affected residents.