Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the individualized needs of four residents, as identified through observation, interview, and record review. One resident with multiple diagnoses, including diabetes and a stage 3 pressure ulcer, did not have a care plan addressing the pressure ulcer or its prevention, despite ongoing wound care and physician orders for barrier cream. Another resident receiving continuous oxygen therapy for acute respiratory failure and chronic obstructive pulmonary disease lacked a care plan for oxygen administration or management of respiratory conditions, even though physician orders specified oxygen requirements and the resident was observed using oxygen. A third resident with a urinary catheter and moderate cognitive impairment required assistance with grooming and hygiene but had no care plan addressing ADL support or catheter care. Observations revealed the resident's catheter was not secured, and nail and facial hair care were not provided, despite the resident's cooperation during care. Staff did not offer or document grooming services, and the care plan did not reflect these needs. The fourth resident, admitted for wound care following a partial foot amputation due to diabetic complications, had no care plan addressing diabetes management or wound care, even though the resident was observed with a wound dressing and ambulating independently. Facility policy requires that comprehensive, person-centered care plans be developed within seven days of completing the MDS assessment, addressing all identified needs and services. However, the care plans for these residents did not include measurable objectives or timeframes for their specific medical, nursing, and psychosocial needs, as required by professional standards and facility policy.