Failure to Develop Comprehensive Care Plans for Assistive Device Use, Community Outings, and Refusal of Care
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by policy and regulation. For one resident with a history of muscle weakness and use of a motorized wheelchair, the care plan did not document the use of the assistive device or the resident's independent community outings, despite the resident regularly leaving the facility unsupervised in their motorized wheelchair. Staff interviews revealed a lack of awareness regarding the resident's use of the motorized wheelchair and their independent outings, and the care plan lacked specific interventions or safety measures related to these activities. For another resident diagnosed with anxiety disorder, hemiplegia, hemiparesis, and dementia, the care plan did not address the resident's consistent refusal of incontinent care. Facility documentation and staff interviews confirmed that the resident often refused to be changed, which posed a risk for skin breakdown. Although staff were instructed to notify the resident's representative and re-approach the resident when care was refused, these interventions were not included in the resident's care plan. The facility's policy required that comprehensive, person-centered care plans be developed for each resident, incorporating identified problem areas, risk factors, and promoting resident safety. However, the care plans for both residents lacked documentation of key needs and interventions, including assistive device use, independent outings, and refusal of care, as well as associated safety measures and communication protocols.