Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, specifically neglecting to address resident relationships and a contracture management need. For multiple residents who were in consensual, non-sexual relationships or cohabitating, the care plans did not include any mention of these relationships, despite staff and family awareness. Interviews with staff, including the DON, ADON, and Executive Director, revealed uncertainty or lack of clarity about whether such relationships should be care planned, even though the Regional MDS Coordinator and other staff acknowledged the importance of including these aspects to ensure resident rights, privacy, and safety. In the case of a resident with a left-hand contracture, the care plan did not reflect the need for or use of a splint or brace, despite therapy orders and documentation in the facility's contracture management logs. Observations showed the resident without the prescribed splint, and interviews with staff indicated a lack of awareness or follow-through regarding the order and its inclusion in the care plan. The Director of Rehabilitation confirmed that the splint was necessary and should have been care planned, but noted that the order had been discontinued without his knowledge and that the care plan was not updated accordingly. Record reviews and staff interviews consistently demonstrated that care plans were not updated to reflect all current physician orders, therapy recommendations, and resident needs, particularly in the areas of psychosocial relationships and contracture management. The facility's own policy required the interdisciplinary team to review practitioner notes and orders and implement a comprehensive care plan, but this was not done for the residents in question. As a result, staff may not have been fully informed of or able to address the individualized needs of these residents.