Failure to Develop Individualized Care Plan for Resident's Harmful Behavior
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions for a resident who exhibited the behavior of wrapping the bed remote cord around his arms. Despite multiple observations and staff interviews confirming that the resident had been engaging in this behavior since early May, and that it resulted in skin discolorations on both arms, there was no care plan in place to address this specific issue. The resident had a history of dementia, anxiety, depression, and peripheral vascular disease, and required varying levels of assistance with daily activities. The absence of a care plan was confirmed during a review of the resident's records with the Director of Nursing, who acknowledged that a care plan should have been created when the behavior was first noted. Staff, including a Licensed Vocational Nurse and a Certified Nursing Assistant, reported observing the resident wrapping the cord around his arms, and a Treatment Nurse documented multiple areas of skin discoloration on both forearms. The facility's policy and procedure required that identified problem areas and risk factors be incorporated into the care planning process, but this was not done for the resident's cord-wrapping behavior. As a result, necessary care and services were delayed, leading to the development of skin discolorations on the resident's arms.