Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for several residents, as required. Specifically, care plans for five residents did not address critical aspects of their care, including code status, activities of daily living (ADL) needs, use of wander guards, and authorized electronic monitoring. These omissions were identified through observation, interviews, and record reviews, which revealed that care plans were either missing or not updated to reflect current orders and resident needs. For example, one resident with dementia and heart failure had an active full code order, but this was not reflected in the care plan. Another resident with severe cognitive impairment and a need for assistance with personal care lacked care plan documentation for both ADL status and code status. Additional residents with diagnoses such as dementia, heart problems, and adult failure to thrive were found to have care plans that did not address DNR status, ADL ability, use of a wander guard, or consent for electronic monitoring, despite these being present in their medical records or observed during the survey. Interviews with facility staff, including the DON and Administrator, confirmed that these care plan omissions were due to oversight and a lack of timely updates. Staff acknowledged that care plans were typically updated with MDS assessments or when significant changes occurred, but in these cases, updates were missed. The facility's policy requires interdisciplinary care planning based on comprehensive assessments, but this process was not consistently followed for the residents reviewed.