Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to the management of a self-releasing seat belt for one resident and the correct settings of a low air loss mattress for another. For the first resident, who had diagnoses including cerebral palsy, paraplegia, contractures, and impaired cognitive skills, the care plan did not include specific interventions or services for the use of a self-releasing seat belt on his motorized wheelchair. Observations showed that staff placed the seat belt on the resident and required multiple prompts before he could release it himself. Interviews with facility staff, including the MDS Coordinator, LVNs, DON, and Administrator, confirmed that the use of the seat belt should have been care planned with interventions to ensure safety and proper monitoring, but this was not done. For the second resident, who had contractures, dementia, severe malnutrition, and was nonverbal and dependent for all ADLs, the care plan included the use of a low air loss mattress for pressure relief due to a history of deep tissue injury. However, the mattress was observed to be set incorrectly, and staff interviews revealed that the settings were not based on the resident's current weight and there was no physician order specifying the correct settings. The ADON and other staff acknowledged that incorrect settings could lead to increased pressure and potential skin injury, and that the care plan and orders should have included specific mattress settings based on the resident's weight. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables to meet each resident's needs, derived from thorough assessments. In both cases, the lack of specific interventions and failure to implement or update care plans as required led to the deficiencies identified by surveyors. Staff interviews consistently indicated that the absence of these care plan details could result in unmet needs and safety concerns for the residents involved.