Failure to Develop and Implement Individualized Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, revise, and implement individualized comprehensive care plans for multiple residents, as required by policy and regulation. For one resident with chronic obstructive pulmonary disease (COPD) and a history of heart failure, morbid obesity, and diabetes, the care plan did not include specific goals or interventions for the management of respiratory care and oxygen therapy, despite a physician's order for oxygen and the resident being observed receiving oxygen. Documentation was inconsistent, with no evidence in the Medication Administration Record or progress notes that oxygen was administered as ordered, and the care plan lacked measurable objectives or timetables for monitoring the resident's respiratory status. Staff interviews confirmed that the care plan was not updated to reflect the resident's current needs, and the facility's own policies regarding care plan development and revision were not followed. Additionally, the same resident was readmitted with a reddish/purplish discoloration and hematoma to the right trunk area, but the care plan did not address this new skin issue. There was conflicting documentation between the body check and the readmission skin assessment regarding the presence of skin issues, and no care plan or interventions were developed for the hematoma. Staff acknowledged that the lack of a care plan for this condition meant there was no ongoing assessment or monitoring, which could lead to further complications. The facility's policy required care plans to be updated with new or changed conditions, but this was not done in this case. Another resident with a history of hemiplegia, functional quadriplegia, and high risk for skin breakdown was found to have a reopened Stage 3 pressure injury and moisture-associated skin damage (MASD). The care plan did not include individualized interventions for the new MASD, and staff failed to provide timely incontinence care and repositioning as required. Observations showed the resident remained in the same position for extended periods, and staff interviews confirmed that care was not provided every two hours as indicated in the care plan and facility policy. The lack of updated care plans and failure to implement required interventions contributed to the risk of worsening skin conditions for this resident.