Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two of five residents reviewed. For one resident with severe cognitive impairment, multiple diagnoses, and a recent admission, the care plan lacked specific, individualized information in focus areas such as hypertension, adjustment to the facility, trauma history, and behavioral problems. Interventions were generic and did not address the resident's unique triggers, behaviors, or needs, nor were they updated as required at the 14-day mark or with subsequent revisions. Observations showed the resident required frequent 1:1 staff attention, wore a wander guard, and exhibited behaviors such as wandering and difficulty with redirection, none of which were adequately addressed in the care plan. Another resident, who had intact cognition and multiple medical conditions including a lumbar fracture, hypertension, anxiety, depression, and chronic pain, also had an incomplete care plan. The plan did not include individualized interventions for psychotropic medication use or behavioral issues, and failed to address anxiety and depression altogether. Interventions for skin integrity were not resident-specific, and documentation of actual skin impairments or treatments was missing. Revisions to the care plan did not consistently reflect the resident's current status or needs. Interviews with facility leadership confirmed that care plans were expected to be complete and person-centered, but acknowledged that the plans reviewed were incomplete and lacked current, individualized information. The facility's policy required comprehensive care plans with measurable objectives and timeframes to be developed within specified timeframes, but this standard was not met for the residents reviewed.