Failure to Develop and Implement Comprehensive, Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including metabolic encephalopathy, end stage renal disease, diabetes with mononeuropathy, and major depressive disorder. The care plan incorrectly identified the resident's dialysis port as a central IV line and included interventions related to IV access that were not applicable, as the resident only had a dialysis port. Additionally, the care plan did not address the resident's activity preferences or her reported visual impairment, both of which were identified through interviews and record review. The resident expressed difficulty participating in activities due to her vision problems and stated a need to see an eye doctor, which had not been addressed in her care plan. Interviews with facility staff revealed a lack of awareness regarding the resident's visual issues and the absence of an activity care plan. The Activity Director noted the resident's preference to stay in her room and her interest in certain personal items, but there was no documented plan to support her activity needs. The MDS Coordinator and DON both confirmed that the care plan contained inaccuracies regarding the resident's IV status and that they were unaware of her visual concerns. The facility's policy requires comprehensive care plans with measurable objectives and timeframes based on resident assessments, but this was not followed in the resident's case.