Failure to Implement Care Plan Intervention for Specialized Call Light
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including muscle wasting, multiple sclerosis, and chronic pain syndrome. The resident was assessed as having moderate cognitive impairment and required substantial to maximal assistance with mobility and transfers. The care plan, initiated in March, specified the use of a pad-type call light as an intervention due to the resident's inability to use a traditional call light. Despite this documented intervention, observations and interviews revealed that the resident did not consistently have access to the pad-type call light. On multiple occasions, the resident struggled to use the traditional call light and often relied on a roommate or self-ambulation to seek staff assistance. Staff interviews indicated a lack of awareness regarding the resident's need for the specialized call light, and the care plan intervention was not consistently communicated or implemented. The facility's own policies require that care plans include measurable objectives and appropriate interventions to meet residents' needs, and that staff follow and update care plans as necessary. However, the failure to provide the pad-type call light as care planned resulted in the resident not receiving the necessary assistance to alert staff, as documented through direct observation, resident statements, and staff interviews.