Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by their own policy and federal regulations. For one resident with diagnoses including pneumonia and COPD, documentation showed the resident experienced shortness of breath and had a physician's order for nebulizer treatments as needed. However, the resident's care plan did not include any interventions or guidance related to nebulizer use or management of shortness of breath. This omission was confirmed by both the MDS Coordinator and the Director of Nursing, who acknowledged that respiratory needs and nebulizer treatments should have been addressed in the care plan. For another resident admitted with orthopedic aftercare needs, muscle weakness, and cervical spinal stenosis, records indicated the resident experienced severe pain, received as-needed pain medication, and that pain occasionally interfered with sleep. Despite this, the resident's care plan did not address pain management or include any related interventions. The MDS Coordinator and the Director of Nursing both confirmed that the care plan should have included pain as a focus area, based on the resident's assessment and physician's orders.