Failure to Develop and Implement Comprehensive, Measurable Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, specifically neglecting to include measurable objectives and timeframes to address their medical, nursing, and psychosocial needs. For one resident with severe cognitive impairment and multiple diagnoses, the care plan addressing dehydration risk was incomplete, lacking individualized details and a specific timeframe for the goal. The interventions listed, such as offering additional fluids, were not sufficiently tailored or updated to reflect the resident's current condition. Additionally, the facility did not ensure that care plan interventions for diversional activity deficits, such as 1:1 and in-room activities, were implemented and documented for multiple residents with severe cognitive impairment and various mental health diagnoses. Review of activity logs over several weeks showed that these residents were repeatedly not provided with the required 1:1 or in-room activities as outlined in their care plans. Interviews with staff confirmed that not all residents received these interventions, and documentation was inconsistent or missing for significant periods. Staff interviews revealed a lack of clarity and consistency regarding responsibility for implementing and documenting activities. The activity director and assistant acknowledged gaps in providing and recording 1:1 activities, and the interdisciplinary team members described expectations for care plan updates and monitoring that were not met in practice. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and regular updates, but these standards were not upheld, resulting in unmet resident needs.