Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to transfer assistance and call light accessibility. One resident, with a history of right tibial shaft fracture, morbid obesity, generalized muscle weakness, and lack of coordination, experienced a fall and injury during a transfer from bed to wheelchair. The resident, who was cognitively intact and non-weight-bearing on the right leg, requested assistance from a CNA. The CNA did not provide hands-on assistance or use a gait belt, instead attempting to grab the resident's loose pants, which failed to prevent the fall. The resident sustained a laceration to the right knee and a head injury, requiring hospital transfer. The care plan for this resident included interventions for fall risk and assistance with transfers, but these were not adequately implemented by staff during the incident. Another resident, with multiple limb amputations and moderate to severe cognitive impairment, required total assistance for all activities of daily living. The care plan for this resident did not address the inability to use upper extremities to activate the call light, despite documentation that the call light should be kept within reach at all times. Observations revealed that the call light was frequently placed out of reach, and the resident was unable to summon assistance independently. The resident reported having to call out loudly for help, and staff confirmed the call light was not reliably accessible. The care plan failed to include specific interventions or adaptive equipment to address the resident's unique needs for call light access. These deficiencies were identified through observations, staff and resident interviews, and record reviews, which demonstrated that the facility did not ensure care plans were comprehensive, measurable, and tailored to the residents' individual needs. The lack of proper implementation and documentation of care plan interventions led to actual harm in one case and placed another resident at risk of unmet needs.