Failure to Develop and Implement Comprehensive Care Plan for Dependent Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with quadriplegia, resulting in the omission of necessary interventions for eating assistance. The resident, a male with quadriplegia and muscle atrophy, was entirely dependent on staff for all activities of daily living (ADLs), including eating, transfers, and personal care. Despite this, the resident's care plan did not include eating as an intervention, and the Kardex did not specify the required level of assistance for feeding, although it did provide details for transfers and other ADLs. Observations and interviews with the resident and multiple staff members, including CNAs and an LVN, confirmed that the resident required a one-person assist for eating and a two-person assist with a mechanical lift for all other ADLs. Staff reported relying on the Kardex to determine the level of care needed, but the Kardex lacked clear instructions regarding eating assistance. The omission was attributed to a failure to check off the relevant task during the resident's baseline care plan update upon re-admission. The facility's policy required the interdisciplinary team to develop a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident, based on their comprehensive assessment. However, the care plan and Kardex for this resident were not updated to reflect the actual assistance required for eating and transfers, as confirmed by staff interviews and record reviews. This failure could result in the resident not receiving individualized care and services to meet his needs.