Failure to Implement Person-Centered Care Plan and Monitor Resident Symptoms
Penalty
Summary
The facility failed to ensure that nursing staff implemented a person-centered care plan for a resident with multiple complex medical conditions, including hemiplegia, hemiparesis following a nontraumatic intracerebral hemorrhage, acute kidney failure, and neuromuscular dysfunction of the bladder. The resident was documented as having fluctuating capacity to understand and make decisions, and was assessed as moderately impaired in cognitive skills, requiring substantial to maximal assistance with daily activities. The care plan specifically identified increased confusion and physical abusiveness towards staff, with an intervention to monitor for worsening symptoms. Despite these documented needs and interventions, interviews and record reviews with nursing staff and the DON revealed that there was no documentation or evidence that the care plan was implemented, specifically regarding the monitoring of the resident's symptoms of confusion and physical abusiveness. The facility's own policy required that qualified staff be notified of their responsibilities and that interventions be carried out as specified in the care plan. However, for several months, there was no monitoring record or documentation to indicate that staff had followed the care plan interventions for this resident.