Failure to Initiate Personalized Care Plans for Residents
Penalty
Summary
The facility failed to initiate personalized care plans for four residents, leading to deficiencies in addressing their specific needs. Resident #48, who has severe cognitive impairment and is dependent on staff for personal care, exhibited combative behavior during care. However, there was no care plan addressing these aggressive tendencies, despite staff being aware of the behavior. Interviews with staff revealed that the MDS Coordinator would only create a care plan for combative behavior after an incident occurred, rather than proactively addressing the issue. Resident #74, with a slight cognitive impairment, experienced pain during care, which led to an allegation of physical abuse by a CNA. The care plan for pain was only initiated after the incident, despite the resident's known history of expressing pain during care. Staff interviews indicated that the resident often screamed in pain during care, yet the care plan did not address this issue until after the incident was reported. Resident #2, who is on anticoagulant therapy, did not have a care plan addressing the use of Rivaroxaban, despite having a physician's order for the medication. The MDS Coordinator confirmed the oversight, as the care plan only mentioned medication for Peripheral Vascular Disease. Resident #31, who was on contact precautions due to a bacterial infection, did not have a care plan for these precautions. The Director of Nursing acknowledged the lack of documentation for a repeat urine culture and the continuation of contact precautions, which were not reflected in the care plan.