Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by regulation. Specifically, care plans did not include individualized, measurable objectives and timeframes to address residents' medical, nursing, and psychosocial needs identified in their assessments. For several residents, care plans lacked specific instructions regarding transfer methods, such as the use of gait belts, mechanical lifts, or stand aids, despite documented needs for substantial or maximal assistance. Observations and interviews revealed that staff often did not use gait belts during transfers, and care plans did not specify the required level of assistance, leading to unsafe transfer practices. In one instance, a resident fell and sustained a laceration during a transfer when staff failed to provide hands-on assistance or use a gait belt, as required by her condition and facility expectations. Another resident with a left-hand contracture did not have a comprehensive care plan addressing contracture management, despite observable limitations and the presence of therapy devices in her room. Interviews with staff and therapy personnel indicated that there was no written plan or documentation for the use of contracture management devices, and restorative care for the contracture had been discontinued without a formal plan or communication to nursing staff. The resident reported that staff rarely assisted with her contracture devices or nail care, and observations confirmed the lack of consistent intervention. Additionally, a resident with a diagnosis of PTSD did not have a care plan that identified her specific triggers or individualized interventions, despite her mental health history and the facility's process for collecting trauma histories. The social worker responsible for trauma-related care plans was unaware of the resident's PTSD diagnosis and had not documented any triggers or interventions. Another resident with recurrent UTIs and prophylactic antibiotic use did not have a care plan addressing infection management or monitoring for side effects, even though she had multiple documented infections and ongoing antibiotic therapy. These deficiencies were identified through observation, interview, and record review, and were confirmed by facility leadership.