Failure to Accurately Reflect Resident Preferences and Needs in Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans accurately reflected the needs and preferences of three residents, as identified through observation, interviews, and record review. One resident, a cognitively intact female with multiple diagnoses including diabetes, malnutrition, depression, and metabolic encephalopathy, expressed a clear preference for only female staff to provide her personal and incontinent care. Despite communicating this preference to several staff members, her care plan did not document this need, and some staff were unaware of her wishes, resulting in her being pressured to accept care from male staff during a weekend. Another resident, a female with severe cognitive impairment and a diagnosis of dementia and depression, preferred only female aides except for one specific male CNA. Both the resident and her family had to repeatedly inform staff of this preference when male aides were assigned to her, as it was not reflected in her care plan. While some staff were aware of her wishes through verbal communication, others were not, and the care plan did not specify her preference or the exception for the one male CNA. A third resident, a male with severe hearing impairment, moderately impaired vision, and aphasia following a stroke, had no documentation in his care plan regarding his communication or sensory deficits. Staff interviews revealed inconsistent awareness of his needs, with some staff noting his hearing and vision issues and others unsure. The responsible party also confirmed the resident's significant impairments, but these were not addressed in the care plan, leaving staff without clear guidance on how to communicate with or care for him.