Failure to Develop Person-Centered Care Plans with Measurable Objectives
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two of eight sampled residents. For one resident with an indwelling urinary catheter and a history of spinal cord dysfunction and obstructive uropathy, the care plan did not include specific information regarding enhanced barrier precautions, despite the resident's frequent catheter changes and risk for urinary tract infections (UTIs). The care plan only referenced general infection control precautions and did not address the need for enhanced measures, even though the resident had experienced a UTI and was placed on antibiotics. For another resident with a history of alcohol abuse (in remission) and significant emotional and behavioral needs, the care plan lacked a comprehensive, person-centered focus on emotional and behavioral interventions. Although the resident exhibited emotional instability, anxiety, and concerns about staff interactions, the care plan primarily included monitoring and medication interventions without detailing specific strategies to address the resident's psychosocial needs during episodes of distress. The psychosocial assessment and social service notes documented the resident's emotional challenges and requests for mental health support, but these were not reflected in the care plan interventions. Interviews with facility staff revealed that while the interdisciplinary team was involved in care planning, there were gaps in updating care plans to reflect changes in residents' clinical or psychosocial status. Staff acknowledged that information about enhanced barrier precautions and psychosocial interventions should have been included in the care plans but were not consistently added following assessments or team discussions. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed for the two residents in question.