Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with disrobing behavior. The resident, who had diagnoses including mood disorder, major depressive disorder, and psychotic disorder, was noted to have severely impaired cognition and was dependent on staff for dressing. Despite observations and staff interviews confirming that the resident had been removing her clothes repeatedly over a two-week period, there was no care plan addressing this behavior. Nursing staff acknowledged awareness of the behavior but did not assess or create a care plan to address the resident’s dignity and respect needs related to disrobing. Additionally, the facility failed to implement a care plan for another resident prescribed carbidopa-levodopa for Parkinson Disease. The care plan indicated the need to monitor for adverse effects of the medication, such as dyskinesia, and to alert the physician if necessary. However, review of the Medication Administration Record (MAR) revealed no documentation of monitoring for adverse effects throughout the month. Both the RN and DON confirmed that monitoring should have been documented and that the lack of monitoring could result in adverse effects going unnoticed. Interviews with staff, including the DON and Pharmacy Consultant, confirmed that the facility did not follow its own policy and procedure for comprehensive, person-centered care planning. The policy required measurable objectives and timetables to meet residents’ needs, including monitoring for medication side effects and addressing behavioral issues. The failure to develop and implement appropriate care plans for both residents resulted in deficiencies related to maintaining residents’ dignity and monitoring for unnecessary medication use.