Failure to Update and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for three residents. For one resident with severe cognitive impairment and multiple medical diagnoses, the care plan was not updated after incidents involving being found in bed with another resident and a subsequent sexual activity incident. The only care plan in the electronic medical record focused on wandering and general safety, without addressing the new behavioral concerns or interventions related to these incidents. Another resident, also with dementia and additional medical conditions, exhibited inappropriate sexual behaviors on multiple occasions, including being found in bed with another resident and attempting to kiss others. Despite these documented behaviors, the care plan was not updated in a timely manner to include interventions addressing these behaviors. The care plan was only revised after several incidents had already occurred, and prior to that, there were no entries related to his sexual behaviors. A third resident, with severe cognitive impairment and a history of falls, had an initial elopement risk assessment completed that indicated the need for routine monitoring. However, the care plan did not include interventions for routine monitoring as required. Staff interviews revealed that communication lapses between agency nurses and the MDS coordinator contributed to the omission, and the care plan was not updated to reflect the necessary interventions following the assessment.