Failure to Develop and Implement Individualized Care Plan for Resident Needing Supervision
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed the specific needs of a resident with a history of falls, muscle weakness, and lack of coordination, who used a motorized wheelchair. Clinical records showed that the resident required distant supervision when using the wheelchair outdoors and regularly left the nursing unit to visit his wife in another part of the building, with staff awareness. The care plan noted the resident's non-compliance with requesting staff supervision for outdoor wheelchair use, but there was no documented evidence of an individualized care plan or interventions to address his ongoing non-compliance with notifying staff when leaving the building. The Director of Nursing confirmed the lack of compliance and absence of appropriate care planning for this issue.