Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents, as required by its own policies and federal regulations. For one resident with a diagnosis of peripheral vascular disease (PVD) and a physician's order for Eliquis 2.5 mg twice daily, there was no care plan addressing the use of this anticoagulant medication. The resident's medical record indicated moderate cognitive impairment and a need for assistance with personal hygiene and toileting, yet the care plan did not reflect interventions or monitoring related to the medication. Both the Director of Nursing and Infection Preventionist Nurse confirmed during interviews that a care plan should have been initiated upon receipt of the medication order to guide staff in providing appropriate care and monitoring for potential side effects. Another resident, admitted with osteoarthritis, GERD, and a thoracic spine fusion, was assessed as being dependent or requiring significant assistance with activities of daily living (ADLs) such as bathing, dressing, toileting, and was always incontinent of bowel. Despite these findings on the Minimum Data Set (MDS) and baseline care plan, there was no comprehensive care plan addressing the resident's ADL functional abilities or bowel incontinence. Staff interviews confirmed the resident's high level of dependency and need for total assistance with hygiene and incontinence care, but the absence of a care plan meant that interventions such as monitoring for skin breakdown and repositioning were not formally documented or communicated to staff. The facility's policy required that a comprehensive care plan be developed within seven days of completing the MDS assessment, incorporating all goals and interventions from the baseline care plan and updating as needed based on the resident's assessed needs. In both cases, the lack of a comprehensive care plan was acknowledged by nursing leadership and staff, who stated that this omission could hinder staff's ability to provide appropriate and individualized care.