Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with specific medical needs. One resident, admitted with multiple diagnoses including difficulty walking, chronic heart failure, and a history of TIA, did not have a care plan addressing ongoing podiatry needs for long fingernails and toenails since admission. Despite a physician's order for a nail care appointment and the resident's repeated requests for assistance with nail care, there was no documented care plan for podiatry services. The Assistant Director of Nurses (ADON) confirmed that a care plan should have been initiated upon admission but was not. Another resident, admitted with acute osteomyelitis of the left ankle and foot, end stage renal disease, and immunodeficiency, did not have a care plan developed for intravenous (IV) antibiotic therapy with Ceftazidime. The resident had a physician's order for IV antibiotics to treat the bone infection, but no care plan was initiated when the therapy began. The ADON acknowledged that staff did not follow the facility's policy requiring the development of a comprehensive care plan for each resident, including baseline care plans within 48 hours of admission.