Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for several residents, leading to deficiencies in addressing their specific care needs. One resident, admitted with multiple diagnoses including chronic atrial fibrillation and morbid obesity, was observed with an indwelling urinary catheter but lacked a care plan addressing its use, care, or infection prevention. Additionally, the resident's care plan inaccurately described their continence status and did not address their dependence on staff for activities of daily living (ADL) such as bathing and dressing. Another resident, diagnosed with conditions including pulmonary embolism and vascular dementia, had a facility-acquired pressure injury that was not adequately addressed in their care plan. Despite having physician orders for wound care and offloading interventions, the care plan did not include pressure-relieving interventions for the resident's sitting position, which contributed to the development of the pressure injury. Furthermore, the care plan failed to incorporate enhanced barrier precautions related to the resident's wound. Additional deficiencies were noted for residents with psychiatric and cognitive impairments. One resident with bipolar disorder and major depressive disorder was receiving multiple psychotropic medications, yet their care plan did not address these diagnoses or the use of such medications. Another resident with Alzheimer's disease had a care plan that lacked individualized interventions for dementia care, despite the diagnosis being known and discussed during care plan meetings. These omissions highlight the facility's failure to develop person-centered care plans that meet the residents' comprehensive medical, nursing, and psychosocial needs.