Failure to Develop Abuse Risk Care Plans for At-Risk Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans for four residents identified as at risk for abuse. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for initiating and updating abuse risk care plans. The social services director stated that social services is responsible for care plans related to behaviors, mood, and cognitive status, but not for abuse risk care plans, and was unaware of who should complete them. The interim DON indicated that nurses are responsible for nursing-related care plans and believed social services should initiate abuse risk care plans, while the social service assistant reported that abuse risk assessments are completed but not followed by specific abuse care plans, with documentation instead placed under other care plan categories. Record review showed that each of the four residents had completed abuse risk assessments indicating they were at risk for abuse or neglect and that care planning was required. The assessments cited reasons such as physical and mental dependence, impaired mobility, lack of safety awareness, non-verbal communication deficits, and cognitive fluctuations. Despite these findings and the explicit notation that care planning was required, none of the residents had an at risk for abuse care plan initiated in their medical records.