Failure to Implement Comprehensive Care Plan for Positioning Device During Meals
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including dementia, malnutrition, and lack of coordination. The resident's care plan indicated the use of a lateral supporting positioning device (cushion) to assist with upright posture during meals, but this intervention was not consistently implemented. During a lunch meal observation, the resident was found leaning to one side in his wheelchair and unable to eat, with no cushion in place. Staff interviews revealed a lack of awareness and communication regarding the resident's need for the cushion, with some staff unsure of the care plan details and others relying on therapy staff for guidance. Further observations confirmed that the cushion was not always provided as required by the care plan, and staff interviews indicated inconsistent understanding of who was responsible for ensuring the intervention was in place. The facility's own policy required comprehensive care plans with measurable objectives and timeframes, but the care plan for this resident was not fully implemented, resulting in the resident not receiving necessary support to maintain an upright posture during meals.