Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for multiple residents. One resident with catatonic schizophrenia was observed in bed with a 1/3 left bed rail raised, and his record showed an active order for this bed rail to assist with bed mobility and transfers, but there was no corresponding comprehensive, person-centered care plan addressing the bed rail. Another resident with hemiplegia affecting the left dominant side had an order for 1/5 bilateral bed rails to assist with bed mobility and transfers every shift, yet her care plans did not include a comprehensive, person-centered care plan for the use of these bed rails. A third resident, under hospice care and dependent on supplemental oxygen at 2 L/min via nasal cannula for shortness of breath and comfort, had a care plan intervention directing staff to monitor and record oxygen saturation every shift, but there was no documentation that this monitoring and recording occurred as specified. A fourth resident, admitted in November, had no documented activity care plan from admission until an activity care plan was created in early January, despite facility policy requiring an activity evaluation as part of the comprehensive assessment to develop an activities plan reflecting the resident’s choices and interests. These findings were identified through observation, record review, and staff interviews, and were inconsistent with the facility’s policies on comprehensive person-centered care plans, oxygen administration, and activity evaluation.
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