Failure to Implement Comprehensive Person-Centered Care Plan and Therapy Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames for a resident with multiple complex medical conditions, including cerebral palsy, kidney failure, contractures, and dysphagia. The resident was totally dependent on staff for all activities of daily living and had significant communication and mobility limitations. The care plan indicated the need for habilitative physical and occupational therapy services, habilitation coordination, and independent living skills, as agreed upon by the family and local mental health authority. However, there was no evidence that the interventions for speech and occupational therapies were implemented as outlined in the care plan. Interviews with facility staff revealed inconsistencies and lack of documentation regarding the provision and refusal of therapy services. The DON initially reported that the resident was not receiving specialized services due to hospice status, but later confirmed that physical therapy had been provided and occupational therapy was pending approval. The Director of Rehabilitation stated that speech therapy was never recommended and believed the family declined it, but this refusal was not documented in the resident's electronic health record. The facility's policy required the interdisciplinary team to develop and implement a comprehensive care plan in conjunction with the resident and their representative, with explanations documented if participation was not practicable, but this was not followed in this case.