Failure to Develop and Implement Comprehensive, Measurable Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for three residents. For two residents with a history of escalating verbal altercations that progressed to physical altercations, the care plans did not address the earlier verbal incidents, despite documentation in progress notes and incident reports. The care plans were only updated after physical altercations occurred, omitting interventions or objectives related to the ongoing verbal conflicts that had been documented for months prior. One resident, with diagnoses including cerebral infarction and altered mental status but intact cognition, was involved in multiple verbal and physical altercations with another resident. Despite progress notes and investigation reports documenting these incidents, the care plan failed to address the verbal altercations that preceded the physical events. Similarly, the other resident involved, who had moderate cognitive impairment and multiple mental health diagnoses, also had a care plan that did not address the ongoing verbal altercations, even though these were documented in progress notes and incident logs. Additionally, a third resident with a recent surgical wound following hip fracture repair did not have wound care interventions included in her care plan, despite physician orders for specific wound care and documentation of the surgical wound in her assessment. Interviews with facility staff confirmed that wound care should have been included in the care plan and that its omission could lead to communication breakdowns regarding the resident's care. The facility's policy requires comprehensive care plans to include measurable objectives and interventions for all identified needs, but this was not followed for the residents in question.