Failure to Implement and Communicate Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with severe cognitive impairment and significant care needs. For one resident with vascular dementia, diabetes, end stage renal disease, and other conditions, the care plan required two-person assistance for transfers and activities of daily living (ADLs) due to her fragility and risk of injury. Despite this, multiple CNAs admitted to providing care alone, contrary to the care plan, and could not recall if they had assistance on the day the resident was found with a bruise on her face. The care plan interventions were not consistently followed, and staff could not provide a reason for not adhering to the two-person assistance requirement. Another resident with congestive heart failure, colon cancer, Alzheimer's disease, and dementia was also dependent on staff for ADLs and at risk for skin breakdown and bruising due to fragile skin and combative behaviors. The care plan for this resident was inconsistent with the MDS assessment, listing one-person assistance for transfers and ADLs despite the assessment indicating a need for two or more staff. Staff reported difficulty accessing or understanding the electronic care plan system, often relying on verbal reports rather than documented care plans to determine the level of assistance required. Interviews with CNAs and facility leadership revealed that staff were not consistently able to access or interpret care plan information in the electronic system, leading to confusion and inconsistent care. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but these were not effectively implemented or communicated to staff, resulting in care that did not meet the documented needs of the residents.