Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by regulation. For one resident with a diagnosis of attention deficit hyperactivity disorder (ADHD), the care plan did not address this diagnosis, despite it being documented in psychological assessments and confirmed by both the resident and staff. Interviews with the Social Services Director, LVN, MDS Coordinator, and DON confirmed that the ADHD diagnosis was not included in the care plan due to a lack of entry in the electronic system and oversight during MDS look-back periods. Staff acknowledged the importance of care planning for all diagnoses to ensure resident needs are met. Another resident, who was dependent on staff for activities of daily living (ADLs) including personal hygiene, did not have a care plan addressing ADL assistance or fingernail care. Observation revealed the resident's fingernails were excessively long, and the resident expressed a desire for staff assistance with nail care, which had not been provided. Staff interviews confirmed the resident's dependence and the absence of a care plan for these needs. Similarly, a resident with diabetes and insulin dependence did not have a care plan addressing these conditions, despite physician orders for insulin administration and severe cognitive impairment. Staff interviews highlighted the lack of tailored care planning for this resident's specific needs. Additionally, a resident with a history of multiple falls did not have timely updates to the care plan reflecting fall interventions after each incident. Although interventions were discussed and implemented immediately, the care plan was not updated promptly, particularly when falls occurred on weekends. Another resident with multiple complex diagnoses, including severe cognitive impairment and heart failure, had no comprehensive care plan initiated at all. Staff interviews consistently indicated that care plans are essential for guiding care and that the absence or delay in care planning could result in unmet resident needs.