Failure to Implement Person-Centered Care Plan for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for one resident with multiple complex diagnoses, including schizoaffective disorder, bipolar type, type 2 diabetes, hypertensive heart disease, anxiety, a history of falling, and dementia with agitation. The resident was assessed as having severe cognitive impairment and was dependent on staff for eating, mobility, transfers, and personal hygiene. The care plan specifically instructed that the resident should be assisted to the dining room for all meals as part of fall prevention measures. Despite these documented care plan instructions, observations and staff interviews confirmed that the resident was not assisted to the dining room for breakfast or lunch on the day in question. The resident was found in her room with a lunch tray, having only consumed milk and leaving the rest of the food untouched. Multiple staff members, including CNAs and an LPN, acknowledged that the resident should have been assisted to the dining room for meals but was not, in direct contradiction to the care plan.