Failure to Implement Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with multiple complex medical conditions, including Parkinson's disease, benign prostatic hyperplasia, dysphagia, and dementia with severe cognitive impairment. The resident required extensive assistance with activities of daily living (ADLs), including being dependent on staff for toileting, dressing, oral hygiene, bathing, bed mobility, and transfers, and was frequently incontinent of bladder and always incontinent of bowel. Despite these needs being documented in assessments and the Minimum Data Set (MDS), the resident's care plan did not address his incontinence needs, ADL preferences, required level of assistance, or the use of a Hoyer lift with two staff for transfers. Observations and interviews revealed ongoing issues with communication between management and direct care staff regarding the delivery of care, with the resident's representative reporting that care was not consistently provided as discussed in care plan meetings. Direct care staff relied primarily on report sheets rather than the care plans, and only nurses had access to the care plans, with CNAs receiving instructions verbally. The facility's policy required individualized interventions and regular updates to care plans, but the resident's care plan failed to reflect his current needs and required interventions, resulting in a deficiency.