Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, individualized care plans with measurable objectives and timetables for multiple residents, as required by its own care planning policy and professional standards. For one resident with dementia, Parkinsonism, and age-related debility, the record showed that after the resident was identified as the aggressor in a resident-to-resident altercation, there was no documented care plan addressing abuse or risk for abuse, despite an order for CNAs to complete safety checks every two hours. Another resident with obstructive sleep apnea, diabetes mellitus type 2 with hyperglycemia, and hemiplegia/hemiparesis following cerebral infarction had a documented diagnosis of obstructive sleep apnea, a consultation recommending an auto-CPAP, and a physician order for CPAP use at bedtime, but there was no documented respiratory care plan addressing this condition and its management. A further resident with noninfective gastroenteritis and colitis, chronic idiopathic and slow transit constipation, and type 2 diabetes had a grievance filed on their behalf stating that another resident entered their room at night and harassed and assaulted them with a water bottle, and that they no longer felt safe with the aggressor on the same floor. Although staff reported placing a stop sign across this resident’s door after learning of the grievance, there was no documented evidence that a care plan for abuse or risk for abuse was developed and implemented with specific interventions after the resident was identified as the victim of a resident-to-resident altercation. Interviews with staff further described systemic issues with care planning. One LPN stated that if they noticed something that needed to be added to a resident’s care plan, such as fall risk, they would notify the unit manager, indicating reliance on informal communication rather than a documented, comprehensive process. The DON stated that care planning was a significant issue at the facility and cited a lack of RNs to assist with care planning. The Administrator stated that care plans should be individualized and that care plans assure residents are safe and cared for accordingly, underscoring that the identified omissions in abuse, respiratory, and other condition-specific care plans were inconsistent with the facility’s stated expectations and written care planning policy.
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