Failure to Develop and Implement Comprehensive ADL Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed the activities of daily living (ADL) assistance needs for three residents. For one resident with hemiplegia, pain, peripheral vascular disease, and hypertension, the care plan did not include her ADL assistance requirements, despite documentation in the MDS indicating she required extensive assistance from two staff for bed mobility and was dependent for toileting hygiene. An incident occurred where this resident, while receiving peri-care from a CNA, rolled off the bed when left unattended as the CNA left to get supplies, resulting in a fall. Subsequent assessments and hospital imaging revealed a femoral fracture, though the timing and location of the injury were disputed. Another resident with a history of wedge compression fracture, dementia, and anxiety was also found to have a care plan that did not address her ADL assistance needs, despite being dependent on staff for personal hygiene, bathing, and requiring maximum assistance with toileting and dressing as documented in her MDS. Observations confirmed that she relied on staff for assistance during daily activities. A third resident, diagnosed with dementia, falls, and muscle weakness, similarly had a care plan that failed to address her substantial to maximum assistance needs for lower body dressing and bathing, as well as moderate assistance for upper body dressing and footwear, and touch assistance for toileting and eating. Interviews and observations confirmed that staff provided assistance as needed, but the care plan did not reflect these requirements. The DON acknowledged responsibility for care plans and stated they were developed collaboratively and reviewed at least quarterly or with changes in resident needs, but the care plans in question did not include the necessary ADL interventions.