Failure to Individualize Care Plans for Bed Placement Preferences
Penalty
Summary
The facility failed to develop individualized care plans for three residents, as required by regulation. Clinical record reviews, observations, and interviews revealed that the care plans for these residents did not address specific needs and preferences related to bed placement. For one resident with confusion, a hip fracture, and dementia, the care plan did not mention that the bed was positioned against the wall, despite this being observed in the resident's room. Another resident, who was alert with some confusion and had dementia, also had a care plan that omitted her preference to keep her bed against the wall. A third resident, who was alert and oriented with a diagnosis of schizoaffective disorder, similarly had a care plan that did not include her preference for bed placement. These omissions were confirmed during an interview with the Director of Nursing, who acknowledged that the care plans should have included information about the residents' beds being against the wall. The lack of individualized care planning for these residents was identified through comprehensive and quarterly MDS assessments, as well as direct observation and staff interviews.