Failure to Individualize and Revise Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to revise and individualize the care plan for a resident with multiple comorbidities, including chronic pain, mood and adjustment disorder, cancer, and a history of respiratory failure. The resident had recent allegations of abuse related to ADL care, and the care plans reviewed did not contain interventions tailored to the resident's specific mental health, behavioral, or ADL needs. Instead, the care plans included generic interventions such as administering medications, referring to psychiatric services, and monitoring mood, without addressing the resident's established patterns of medication refusal, noncompliance, or specific behavioral concerns. The care plans also lacked descriptions of the resident's confabulatory statements or hallucinations, and did not provide staff with individualized strategies to address these behaviors. Despite documentation in the medical record of the resident's refusals and noncompliance, the interventions remained non-specific and did not guide staff on how to provide patient-centered care. During interviews, the DON stated that care plans were updated, but only care plan progress notes and evaluations were provided, not actual updates to the care plan itself. The DON also asserted that no interventions could be put in place for this resident, and there was no care plan addressing the resident's verbalized preferences or specific needs related to ADL care. This lack of individualized care planning was evident despite ongoing concerns and repeated refusals by the resident.