Failure to Develop and Update Person-Centered Care Plans Reflecting Resident Preferences
Penalty
Summary
The facility failed to develop and update person-centered care plans for two residents, resulting in unmet needs and preferences. One resident, admitted with diabetes mellitus and legal blindness, had care plans that did not include specific interventions or accommodations for her blindness, such as explaining the location of personal belongings or her lunch tray. Despite being able to communicate her needs, there was no documentation of her blindness on her electronic medical record dashboard, and no posted communication in her room to alert staff. The resident reported having to remind staff of her blindness, especially when registry staff unfamiliar with her routine were assigned to her care. Multiple staff interviews confirmed a lack of consistent communication and orientation for temporary staff, which contributed to the oversight of the resident's needs. Another resident, admitted with diabetes mellitus, major depressive disorder, anxiety disorder, and personality disorder, expressed a preference not to be woken early for blood glucose checks and had specific times he preferred for medication administration. However, these preferences were not documented in his care plan or progress notes. Staff acknowledged the resident's preferences and noted that he would post notes on his door when he did not want to be disturbed, but there was no formal record of these preferences in his care documentation. The facility's policy required that any accommodations or adaptive devices provided to assist residents with communication needs be reflected in the resident's plan of care and updated as appropriate. However, the care plans for both residents lacked documentation of their individual needs and preferences, reducing the facility's ability to provide consistently communicated, personalized care.