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 residents with specific medical needs. For one resident with a PEG tube, the care plan did not address the presence of the feeding tube or Enhanced Barrier Precautions (EBP), despite physician orders for PEG tube stoma care and the resident's ongoing transition away from tube feeding. Interviews with MDS Coordinators confirmed that the required care plans were not created, with one staff member acknowledging the omission was an oversight. Additionally, another resident who was on contact precautions for a urinary tract infection with ESBL did not have a care plan addressing these precautions. Review of the electronic health record and physician orders confirmed the resident was on contact precautions, but this was not reflected in the care planning documentation. Both deficiencies were identified through observations, interviews, and record reviews, and were not in accordance with the facility's own care planning policy.