Failure to Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as identified through observation, interviews, and record reviews. For one resident, who had diagnoses including dementia, chronic kidney disease, anxiety, and hypertension, the care plan required a fall mat to be in place while the resident was in bed due to a recent fall. However, during multiple observations, the fall mat was found folded and not in use while the resident was in bed. Staff interviews revealed that the resident had previously moved the mat herself and sometimes requested its removal, but there was no documentation explaining why the intervention was not in place as required by the care plan. For another resident with diagnoses of dementia, urinary retention, heart failure, and hypertension, the care plan did not include the use of an antidepressant medication, despite the resident having an active order for citalopram for depression. The resident's medication administration record confirmed ongoing use of the antidepressant, but this was not reflected in the care plan. Interviews with the DON and Administrator confirmed that the care plan should have included this medication and the associated diagnosis. The facility's policy requires that care plans be comprehensive, person-centered, and updated to reflect all relevant diagnoses, medications, and interventions based on ongoing assessments. The failures identified in these two cases resulted in care plans that did not accurately reflect the residents' needs or the interventions required to address those needs, as evidenced by the lack of a fall mat in use and the omission of an antidepressant medication from the care plan.