Failure to Develop Comprehensive, Person-Centered Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan for one resident. Record review showed the resident was admitted with multiple diagnoses, including age-related osteoporosis without current pathological fracture, epileptic spasms not intractable and without status epilepticus, GERD without esophagitis, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, unspecified insomnia, recurrent moderate major depressive disorder, and a need for assistance with personal care. These conditions were pertinent to the resident’s care needs. Review of the resident’s care plan dated 01/21/26 revealed it addressed only certain issues: risk for elopement related to an elopement evaluation risk score, dementia placing the resident at risk for altered nutritional status, and a history of stroke affecting behavior with a tendency to make demands and inappropriate comments to staff. The care plan did not address other documented conditions such as epileptic spasms, GERD, cerebral infarction-related deficits, insomnia, major depression, and ADL needs. In an interview, the DON confirmed that these conditions were not included in the care plan and acknowledged that the plan was not person-centered and did not reflect the resident as a whole.
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