Failure to Develop and Implement Individualized Care Plan for Adult Brief Adjustment
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan with measurable objectives and interventions to address a resident's needs regarding the adjustment and fitting of an adult brief. The resident, who had a history of cerebral infarction, hemiplegia, and left above-knee amputation, required significant assistance with mobility and personal care. Despite repeated complaints from the resident about discomfort, embarrassment, and avoidance of activities due to improper fitting and leakage of the adult brief, the care plan did not include specific interventions to address these concerns. Observations and interviews revealed that the resident's adult brief was often applied incorrectly, resulting in wet clothing and discomfort. Staff, including a CNA and the DON, acknowledged the ongoing issue and the lack of detailed instructions or interventions in the care plan for proper adjustment of the brief. The resident expressed frustration with staff not following her instructions and reported that her complaints had not been addressed since admission. A review of the care plan and interdisciplinary team meeting notes confirmed that the interventions were generic and did not address the resident's specific needs for adult brief adjustment. The care plan focused on managing aggressive behavior during diaper changes but did not provide objective, measurable goals or resident-centered strategies for ensuring proper brief application. Facility policies required comprehensive, person-centered care plans, but these were not followed in this case.