Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical needs. The resident, a male with morbid obesity, a BMI between 50.0-59.9, and metabolic encephalopathy, was admitted with significant impairments in mobility and required total dependence for several activities of daily living (ADLs) such as toileting, bathing, and lower body dressing. Despite these needs, the care plan lacked specific interventions for required ADL care and assistance, did not specify the number of staff needed for care, and failed to provide measurable objectives or timeframes for meeting the resident's needs. The care plan also included only placeholder information for bed mobility and did not address the resident's total dependence or the level of assistance required. Additionally, the care plan was incomplete regarding the resident's nutritional needs. Although there was a physician order for a cardiac diet and semaglutide for weight management, the care plan did not include interventions for the cardiac diet or a weight management program. There was no direction on ideal nutritional intake, weight goals, or monitoring strategies. Interviews with staff revealed that the resident was allowed to eat snacks in addition to the prescribed diet, and staff were expected to monitor and record food intake, but these practices were not reflected in the care plan. The MDS Coordinator acknowledged that the care plan was incomplete and lacked necessary details, attributing this to being new in the role and the absence of regular care plan meetings. Further contributing to the deficiency, the facility experienced issues with their electronic medical record system, which resulted in baseline care plans being opened by LVNs and required manual intervention to create comprehensive care plans. The DON and other staff confirmed that these technical issues, along with unclear responsibilities and lack of regular oversight, led to incomplete care plans. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not achieved for the resident in question.