Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by regulation. For one resident with severe cognitive impairment and a history of wound care refusal, the care plan did not reflect the resident's refusals of wound treatment prior to a certain date, despite documentation and staff interviews confirming repeated refusals and the need for daily education involving the resident and family. The wound administration record also showed gaps in documentation for several days, and the care plan was not updated to reflect the resident's right to refuse treatment or the interventions used to address this issue. For another resident with moderate cognitive impairment and a diagnosis of dementia, the care plan did not address the resident's behaviors of making allegations and accusations about care, even though staff interviews and social work documentation confirmed a pattern of such behaviors. Staff accommodated the resident's preferences and worked with psychiatric and psychological services to address these behaviors, but these interventions and the resident's behavioral history were not included in the care plan. The facility's own policy required care plans to describe services furnished to attain or maintain the resident's well-being and the right to refuse treatment, but these elements were missing for both residents.