Failure to Develop and Implement Person-Centered Care Plan for Resident Requiring ADL Assistance
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for one resident who required supervision and assistance with Activities of Daily Living (ADLs). The resident had multiple diagnoses, including lack of coordination, difficulty walking, dementia, and Parkinson's Disease, and was assessed as having severely impaired cognitive skills and high dependency for various ADLs such as toileting, bathing, dressing, and transfers. Multiple assessments, including the Minimum Data Set and Fall Risk Assessments, indicated the resident was at high risk for falls and required substantial to maximal assistance or supervision for mobility and transfers. Interviews with staff, including a CNA and the Director of Rehab, confirmed the resident needed supervision or touching assistance during walking and transfers. Despite these documented needs and facility policy requiring comprehensive, person-centered care plans, a review of the resident's medical chart revealed no care plan addressing the need for supervision or assistance with ADLs. Staff interviews, including with an LVN and the DON, confirmed that no specific care plan had been developed or implemented for this resident's supervision or assistance needs. The facility's policy emphasized the importance of individualized care planning involving the interdisciplinary team, but this process was not followed for the resident in question.