Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including sepsis, metastatic cancer, severe malnutrition, dysphagia, muscle wasting, and impaired mobility. The resident was at risk for pressure ulcers and required assistance with mobility and personal care. Despite these needs, the care plan did not include measurable objectives or timeframes to address the resident's pressure wound, nor did it provide specific interventions for the resident's refusals of offloading, repositioning, and wound care treatments. Record reviews showed that the resident developed a Stage 2 pressure wound to the sacrum, and documentation indicated noncompliance with turn and repositioning as well as poor food intake. Interviews with staff revealed a lack of clarity and responsibility regarding care plan revisions, particularly in response to the development of wounds and resident refusals. The care plan was not updated to reflect the resident's changing condition or to guide staff on how to address refusals of care, despite facility policy requiring care plan review and revision upon status changes. Facility documentation and staff interviews confirmed that the interdisciplinary team did not consistently collaborate or communicate changes in the resident's condition, and the care plan was not revised to include new or modified interventions as required. This resulted in the absence of a comprehensive, individualized care plan that addressed the resident's medical, nursing, and psychosocial needs as identified in the comprehensive assessment.