Failure to Care Plan for Family Member Interference and Alcohol in Resident’s Environment
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized care plan addressing a resident’s safety needs related to a specific family member whose behavior interfered with care. The resident was admitted and later readmitted with diagnoses including psychoactive substance abuse, respiratory failure, chronic kidney disease, ventilator dependence, and a gastrostomy tube, and had intact cognition with a need for moderate assistance with ADLs per the MDS. Respiratory therapy notes documented a meeting with social services regarding the resident’s family member intervening in the resident’s care and exhibiting aggressive behavior toward staff. A nurse reported that the family member acted suspiciously during visits and had brought beer into the facility on at least one occasion. During interviews, an LVN, an RN supervisor, and the DON each confirmed there was no care plan addressing the family member’s non-compliant behaviors, such as bringing beer into the facility or interrupting the resident’s care, despite awareness of these issues. They each stated that a care plan should have been developed to outline goals and interventions to ensure the resident’s safety and to guide staff in safely and appropriately caring for the resident. Review of the facility’s comprehensive, person-centered care plan policy showed it required measurable objectives and timetables to meet residents’ physical, psychosocial, and functional needs, incorporating identified problem areas and associated risk factors, but this was not carried out for this resident’s situation involving the family member.
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