Failure to Develop and Implement Comprehensive Care Plans for Resident Needs
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans that addressed all of the residents' needs, as evidenced by two specific cases identified during a complaint survey. In the first case, a resident who frequently refused showers did not have a care plan intervention addressing these refusals. Although the resident was offered showers weekly and received bed baths when showers were refused, the care plan only stated that showers were to be offered twice weekly and did not include strategies or interventions to address or manage the refusals. The Director of Nursing confirmed that the care plan lacked interventions for refusals and acknowledged the need for review. In the second case, a newly admitted resident's transfer status was not assessed or documented in the care plan in a timely manner. The admission screener did not contain information on the resident's ability to transfer, and although the MDS assessment indicated the resident was dependent for transfers, the care plan did not include a transfer intervention until after an incident resulting in injury. Documentation of the resident's transfer assistance needs was inconsistent throughout the month, and staff interviews revealed confusion and lack of clarity regarding the resident's transfer status and the appropriate method for transfers. The care plan was only updated to include a transfer intervention after the injury occurred. Multiple staff interviews confirmed that there was a lack of communication and documentation regarding transfer status, with some staff unsure where to find this information in the medical record. The Director of Nursing and other staff acknowledged that the care plan should have included the resident's transfer status to guide care. The failure to timely and accurately update care plans to reflect residents' needs, including interventions for shower refusals and transfer assistance, led to deficiencies in meeting regulatory requirements for comprehensive, individualized care planning.