Failure to Implement Person-Centered Care Plan and Update for Orthopedic Changes
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple diagnoses, including psychosis, schizophrenia, and bilateral calcaneus fractures. The care plan specified that only female staff should be assigned to provide 1:1 assistance with activities of daily living due to the resident's psychosocial needs. However, daily assignment sheets showed that male staff were assigned to provide 1:1 care on two occasions, contrary to the care plan and interdisciplinary team notes. The Director of Nursing confirmed that this assignment was not in accordance with the established care plan. Additionally, the resident's care plan was not updated to reflect a change in orthopedic treatment. After the resident's left foot was placed in a non-weight bearing immobilizer cast, there were no new interventions or protocols added to the care plan regarding the care of the cast or monitoring of circulatory function in the affected foot. The Director of Nursing acknowledged that the care plan did not include the necessary updates or interventions related to the immobilizer cast.