Incomplete and Inaccurate Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex diagnoses, including traumatic brain injury, intellectual disability, schizophrenia, and seizures. The care plan did not include measurable objectives or timeframes to address the resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, the care plan omitted the dates when the resident sustained bruises, such as a right lower leg bruise from swinging his leg over a chair and abdominal bruising from Lovenox injections. Additionally, there were no documented goals or interventions related to the resident's diagnosis of schizophrenia, despite the resident receiving medication for this condition. Record reviews and staff interviews confirmed these omissions. The resident was noted to have severe cognitive impairment, total dependence for mobility and transfers, and was non-communicative during observation. The facility's staff, including the Regional RN, ADO, and Administrator, acknowledged that the care plan and clinical records were incomplete and lacked necessary details to ensure continuity of care. The facility's documentation policy required complete and accurate records, but this was not followed in the resident's case.