Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans that addressed the specific needs of three residents. For one resident with a urinary tract infection and a history of falls, the care plan did not include interventions or monitoring related to the prescribed antibiotic therapy, despite physician orders for cephalexin. The Assistant Director of Nursing confirmed that a care plan for antibiotic therapy should have been initiated to monitor for complications such as nausea, vomiting, diarrhea, and dehydration, but this was not done. Another resident, admitted with acute respiratory failure, congestive heart failure, and pneumonia, had a care plan for oxygen therapy that did not match the physician's orders. The care plan incorrectly indicated the use of humidified oxygen, while the physician's order specified continuous oxygen at two liters per minute without humidification. The Director of Nursing acknowledged that the care plan was inaccurate and should have reflected the physician's order to ensure proper care. A third resident, who spoke Armenian and had moderate cognitive impairment, did not have a communication care plan created upon admission, despite the need for an interpreter being identified in the assessment. The care plan addressing the language barrier was only created after a delay, and both the MDS Nurse Consultant and the Director of Nursing confirmed that the communication care plan should have been established earlier to facilitate effective communication and care.