Failure to Develop and Implement Required Care Plans for Smoking Safety and Fluid Restriction
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by facility policy and physician orders. For one resident with severe cognitive impairment and dependence in daily activities, there was no care plan addressing the resident's smoking behavior and consistent refusal to wear a protective smoker's apron. Observations confirmed the resident's refusal, and staff interviews acknowledged the absence of a care plan to address this risk, despite facility policy requiring such issues to be documented and communicated to all personnel. For another resident with stage 4 chronic kidney disease, type 2 diabetes, and acute systolic heart failure, the facility did not create a care plan reflecting a physician-ordered fluid restriction. The order specified detailed fluid limits for both nursing and dietary staff, but review of the care plan and staff interviews confirmed that no care plan was in place to guide staff in monitoring and implementing the fluid restriction. Facility policy required care plans to be updated with new physician orders or changes in condition, but this was not done for the resident. Both deficiencies were identified through observation, record review, and staff interviews. The facility's own policies outlined the need for individualized, measurable care plans that incorporate physician orders and address identified risks, but these were not followed for the two residents in question.