Failure to Develop Comprehensive Care Plans for Smokers and Roommate Disputes
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for all residents with identified needs. Specifically, care plans were not created for 23 residents in the TRC unit who were identified as smokers, despite documentation confirming their smoking status. Medical record reviews for these residents, including two specific examples, showed no care plan problems were initiated to address their smoking habits or the associated risks. The TRC Program Director confirmed that these care plans were missing during an interview and record review. Additionally, the facility did not develop care plans to address ongoing disputes between two residents regarding whether their shared room door should be open or closed. Documentation showed repeated arguments and incidents between the two residents, including loud altercations and complaints, but no care plan was initiated to address or manage these recurring issues. Interviews with staff and the TRC Program Director confirmed that the disputes were known and discussed among staff, but appropriate care planning was not completed.