Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, individualized care plan interventions for two residents, resulting in the potential for unmet needs. One resident, a female with borderline intellectual functioning, bipolar disorder, and anxiety, was cognitively intact but reported significant anger management issues, particularly towards another resident. Despite her expressed concerns about her anger and interactions with another resident, the care plan only included general interventions for suspiciousness and did not address her specific behavioral concerns or the recent escalation in her anger. Interviews with staff revealed a lack of awareness and monitoring of her behaviors, and there was no clear documentation or update to her care plan following incidents involving the other resident. Another resident, a male with dementia, a history of stroke, and joint replacement, was severely cognitively impaired and exhibited frequent wandering behaviors. He was known to wander the facility, was easily redirectable, and often entered other residents' rooms due to confusion about his own room location. Family and staff interviews confirmed his wandering as a baseline behavior and a means of stress relief. However, his care plan did not reflect his wandering, inability to locate his room, or his tendency to enter other residents' rooms, despite these behaviors being well-documented in progress notes and staff observations. The deficiency was further evidenced by interviews with various staff members, including CNAs, RNs, and LPNs, who either were unaware of the need to monitor the first resident for behavioral issues or confirmed the second resident's wandering without corresponding care plan interventions. The lack of updated, individualized care plans for both residents demonstrated a failure to ensure that care plans were comprehensive, person-centered, and responsive to the residents' current needs and behaviors.