Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for several residents, as required by regulation. For one resident with a chronic skin condition and moderate cognitive impairment, there was a documented pattern of refusing showers, resulting in poor hygiene, strong body odor, and extremely dry skin. Despite repeated refusals and family reports of long-standing hygiene issues, the care plan did not address the resident's refusal of showers or outline interventions to address this behavior. Staff interviews confirmed awareness of the issue, but no care plan was in place to guide consistent care or document effective strategies. Another resident with Alzheimer's disease and depression exhibited wandering behaviors, specifically entering other residents' rooms and rummaging through their belongings, which led to altercations with other residents. Although the care plan addressed wandering in general, it did not specifically address the behavior of entering other residents' rooms. Staff and leadership interviews confirmed that this was a known, ongoing behavior, but it was not reflected in the care plan, leaving staff without clear guidance on how to manage or prevent these incidents. Two additional residents displayed sexually inappropriate behaviors, including exposing themselves and inappropriate physical contact with other residents. In both cases, these behaviors were not included in the residents' care plans, despite being documented in progress notes and incident reports. Staff interviews revealed that these were new or ongoing behaviors that had not been care planned, and the lack of documentation meant that staff were not fully informed or prepared to address these behaviors. The facility's own policy required that care plans include refusals, behaviors, and interventions, but this was not followed for these residents.