Failure to Implement Person-Centered Care Plan Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident with Alzheimer’s disease, dementia with mood disturbance, repeated falls, hypothyroidism, and hyperlipidemia. The resident’s Quarterly MDS showed a BIMS score of 7, indicating severe cognitive impairment, and documented a need for substantial/maximal assistance with showering/bathing and personal hygiene. The resident’s care plan identified an actual fall with minor injury related to poor balance and included an intervention for the resident to eat lunch and supper meals in the dining room. The ADL care plan documented that the resident required total care with all ADLs, including bathing, and specified that the resident was to receive a bed bath on Monday, Wednesday, and Friday, as needed, and be shaved on bath days. Despite these documented interventions, surveyor observations on multiple dates showed the resident in bed eating lunch rather than in the dining room, and with long facial hair that had not been shaved or trimmed. An LPN reported that the resident had received a whirlpool bath the previous day, and during a joint observation with the surveyor, confirmed that the resident’s facial hair needed trimming. The DON also confirmed, during observation and care plan review, that the resident was care planned to receive a whirlpool bath three times per week, be shaved on bath days, and eat lunch in the dining room, and acknowledged that these care plan interventions were not being implemented for this resident.
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