Failure to Develop and Implement Complete Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that included measurable objectives and timetables to meet all of a resident's needs. Specifically, upon admission, the care plan did not address discharge planning for a resident who had multiple diagnoses, including muscle weakness, polyneuropathy, unspecified fractures of the right lower leg and right hand, and was using a right wrist and distal forearm splint. The resident was cognitively intact, able to communicate needs, and required supervision for some activities of daily living, but was otherwise independent with personal hygiene and used a crutch for mobility. Record reviews and staff interviews revealed that the care plan initiated at admission focused on fall risk and recent surgical interventions but omitted both discharge planning and interventions related to the resident's right wrist splint. The Director of Nursing (DON) confirmed that discharge planning was not initiated as required by facility policy, which mandates that discharge planning begin upon admission and be incorporated into the person-centered care plan process. The DON acknowledged that this omission could result in the resident's discharge goals not being identified or met. Additionally, the care plan did not address the presence of the right wrist and distal forearm splint, despite documentation in hospital and occupational therapy records. Staff interviews confirmed that the care plan should have included interventions for the splint to guide staff in supporting the resident's healing process and preventing complications. Facility policy requires that care plans address all identified needs with measurable objectives and timeframes, but this was not followed in the resident's case.