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 dementia and depression, the care plan did not include any mention of his religious preferences or needs, despite the resident being Muslim and having communicated this to staff. The only reference to his religion was a dietary note about a selective menu, but there was no documentation regarding his desire to practice his religion or participate in religious activities. Interviews revealed that the resident felt excluded from religious activities and was not provided alternatives to practice his faith, and several staff members were unaware of his religious background or how to accommodate his needs. For another resident with a diagnosis of PTSD and a history of traumatic brain injury, the care plan did not address his PTSD diagnosis or related care needs. The resident reported that engaging in puzzles at night helped him cope with his trauma, and staff interviews confirmed that he was sensitive to loud noises and required accommodations to avoid being triggered. However, this information was not reflected in his care plan, and some staff were unaware of his PTSD diagnosis or how to support him appropriately. Record reviews and staff interviews indicated a lack of communication and clarity regarding responsibility for updating care plans to reflect residents' religious and psychosocial needs. The facility's policy required person-centered care plans that addressed each resident's preferences and needs, but in these cases, the care plans were incomplete and did not provide measurable objectives or time frames for addressing the identified needs. This failure was confirmed through interviews with residents and staff, as well as review of facility documentation.