Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required by federal regulations. For one resident with diagnoses including generalized anxiety and post-traumatic stress disorder, the care plan did not include a focus or interventions addressing these mental health conditions, despite physician orders and clinical notes indicating the need for monitoring and documentation of related symptoms. Staff interviews confirmed that these diagnoses and their associated care needs were not incorporated into the resident's care plan and needed to be added. For another resident, physician orders and clinical documentation indicated the need for enhanced barrier precautions due to a medical device and wound care requirements. However, the resident's care plan did not address enhanced barrier precautions, and staff interviews, including those with the LPN Unit Manager, DON, and MDS Coordinator, confirmed that this omission was inconsistent with facility expectations and policy. The facility's policy requires the identification of problem areas and the development of targeted interventions, which was not followed in these cases.