Failure to Develop and Implement Comprehensive Care Plans for Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by policy and regulation. For one male resident with a history of muscle weakness, sequelae of cerebral infarction, muscle wasting, and GERD, the care plan did not address his repeated refusal of prescribed medication (protonix). Despite the resident's moderate cognitive impairment and ability to communicate, there were no documented care plan goals, interventions, or tasks related to his medication refusal. Nursing staff reported the refusals to the physician but assumed the issue was already care planned, while the MDS nurse was unaware that such behaviors needed to be included in the care plan. For a female resident with muscle weakness, unspecified dementia, and muscle wasting, the facility did not develop or implement a care plan to address her attempts to get out of bed without assistance. This resident had severe cognitive impairment and was unable to communicate her needs or use the call light. Progress notes documented that she had fallen, resulting in injury and requiring emergency care. Multiple staff interviews confirmed that the resident frequently attempted to get out of bed unassisted and had experienced multiple falls, yet her behaviors were not reflected in her care plan. The MDS nurse was unaware that these behaviors should be care planned, and the DON considered the resident's actions as part of her disease process rather than a behavioral issue requiring care planning. The facility's policy requires the development and implementation of a comprehensive care plan for each resident, including measurable objectives and timeframes to address medical, nursing, mental, and psychosocial needs identified in the assessment. In both cases, the facility did not follow its own policy, resulting in the absence of care plans for significant resident needs and behaviors.