Failure to Develop and Implement Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans that addressed the specific needs and risks of three residents. For two residents with a history of smoking, the care plans did not specify the required level of supervision during smoking activities, despite facility policy and interdisciplinary team notes indicating that such details should be included. The care plans contained general interventions such as education on smoking risks and safe disposal of cigarette butts, but lacked individualized instructions regarding supervision or the use of safety equipment like smoking aprons. Both the RN and DON confirmed that the care plans were not resident-centered and did not provide staff with clear guidance on the necessary interventions to ensure safety during smoking. For another resident prescribed Klonopin, an antianxiety medication with a black box warning, the care plan did not address the specific risks associated with the medication. Although the resident had severe cognitive impairment and was dependent on staff for most activities of daily living, the care plan failed to mention the black box warning for Klonopin, which includes risks of abuse, addiction, dependence, and withdrawal reactions. Both the RN and DON acknowledged that the care plan should have included these details to enable appropriate monitoring and staff awareness of the medication's dangers. The facility's policies and procedures require that comprehensive, resident-centered care plans be developed for each resident, including measurable objectives and timeframes based on the comprehensive assessment. The deficiencies identified in the report were due to the omission of individualized interventions and failure to address specific risks in the care plans, as observed during interviews and record reviews with facility staff.