Failure to Include Resident Behaviors in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all identified needs for a resident with severe cognitive impairment and multiple medical diagnoses, including vascular dementia and urinary retention. Specifically, the care plan did not include documentation or interventions related to the resident's behavior of urinating in inappropriate areas, such as trash cans or the floor, despite evidence of this behavior occurring over a period of approximately six months. The omission was identified during a review of the resident's records and interviews with facility staff, who acknowledged awareness of the behavior but had not ensured it was reflected in the care plan. Interviews with the DON, SW, and ADON revealed that although the behavior had been discussed among leadership and was known to staff, it was not documented in the care plan until after the surveyor's inquiry. The DON confirmed that the behavior should have been included to ensure all staff were aware and could implement appropriate interventions, and that the facility's policy required care plans to be updated as needed to reflect changes in resident behavior. The ADON and SW also indicated that the behavior had not been reported or observed directly, but evidence such as urine in trash cans and odor was present, and the issue had been discussed in meetings. The facility's policy and in-service training required comprehensive care plans to describe all services necessary to maintain the resident's highest practicable well-being, including behavioral interventions. However, the failure to update the care plan as required resulted in a lack of communication among staff regarding the resident's behaviors and the necessary interventions, as confirmed by staff interviews and record reviews.