Failure to Develop and Implement Required Care Plans for Diagnoses and Non-Compliance
Summary
A review of one resident's medical record revealed that, despite diagnoses of Post-Traumatic Stress Disorder (PTSD) and Vascular Dementia, there was no care plan in place addressing these conditions. The resident was cognitively intact and required assistance with activities of daily living. When questioned, the social worker confirmed the absence of care plans for these diagnoses, and the nursing home administrator acknowledged that appropriate care plans should be in place for such conditions. Another resident, who was dependent for all activities of daily living except eating and had a history of encephalopathy, diabetes with neuropathy, kidney disease requiring dialysis, and a pressure ulcer, was observed not using prescribed heel protectors and was known to frequently refuse care, including dietary restrictions. Multiple staff interviews confirmed the resident's pattern of non-compliance, yet there was no care plan addressing this behavior. The facility's own policy requires care plan development and implementation based on comprehensive assessment, which was not followed in these cases.
Penalty
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