Failure to Develop and Implement Timely, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement timely, person-centered care plans for four out of five sampled residents, resulting in deficiencies related to the assessment and management of their medical and behavioral needs. For one resident with a history of heart failure, dementia, psychosis, and repeated falls, staff observed frequent episodes of the resident getting up unassisted and being found on the floor multiple times. Despite these incidents and documentation by staff, the care plan addressing this behavior was not created promptly when the behavior was first observed, as confirmed by the Director of Nursing. Another resident with a diagnosis of osteoporosis did not have an active care plan addressing this condition, even though the diagnosis was documented in the medical record and physician notes. The care planner acknowledged missing the development of a new care plan for osteoporosis, and the risk management nurse confirmed that such a care plan was necessary to address the risk of fractures. Similarly, a third resident with Parkinson's disease, Alzheimer's, and osteoporosis exhibited repeated behaviors of throwing himself on the floor, which were documented by nursing staff over several weeks. However, this behavior was not reported to the care planning team, and no care plan was developed to address the risk of falls associated with this behavior. A fourth resident with atrial fibrillation, epilepsy, and osteoporosis also lacked a care plan for osteoporosis. Additionally, this resident exhibited a persistent behavior of banging the call light on the table, resulting in injury, and had a documented pattern of refusing activities of daily living, including showers. Despite these ongoing behaviors and refusals, care plans addressing these issues were not developed in a timely manner, and the care planning team was not informed promptly. The facility's own policy required comprehensive, person-centered care plans to be developed and updated for changes in condition, new problems, or resident behaviors, but these requirements were not met for the residents involved.