Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents, as required by policy and regulation. For each resident, there was a lack of documentation, development, or implementation of care plans that addressed current diagnoses, care levels, measurable objectives, and timetables to meet their physical, psychosocial, and functional needs. This was identified through observation, interviews, and record reviews, which revealed that care plans were either missing or incomplete for all four residents reviewed. One resident, a 58-year-old female with multiple complex diagnoses and severe cognitive impairment, had no documented care plan since admission, and her family had not participated in a care plan meeting. Another resident, a 63-year-old male with significant medical and cognitive issues, also lacked a documented care plan addressing his current needs. For a female resident with severe cognitive impairment and on hospice care, there was no care plan reflecting her hospice services, goals, or interventions, despite evidence of ongoing hospice involvement. Additionally, a resident with hepatic encephalopathy and a stage 4 pressure ulcer had no updated care plan following an interdisciplinary team (IDT) meeting with her mother, nor documentation of interventions related to wound care and family involvement. Interviews with facility staff, including the administrator, DON, ADON, social worker, and wound care nurse, revealed confusion and lack of clarity regarding responsibility for care plan completion and updates. Staff cited recent transitions in key positions, such as the DON and MDS nurse, as contributing factors to the deficiency. Despite daily meetings to address care plan issues, the required comprehensive care plans were not completed or updated in accordance with facility policy and regulatory requirements.