Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for five residents with specific clinical needs. Two residents were prescribed and receiving aspirin (ASA) as an antiplatelet medication, but their clinical records did not include care plans addressing this therapy. Another resident, who was observed using a urinal at the bedside and had a history of ESBL bacteria in the urine, did not have a care plan reflecting his preference and practice of using a urinal and keeping it on the bedside table. Additionally, a resident with chronic respiratory failure and pulmonary fibrosis was receiving continuous oxygen therapy per physician order, but there was no care plan in place for oxygen use. Finally, a resident who self-administered eye drops, as permitted by physician order, lacked a care plan addressing self-administration of medication. These deficiencies were identified through observation, interview, and record review, and were confirmed by staff interviews and review of facility policy. The absence of individualized care plans for these residents meant that their specific needs and preferences, as well as the services required to maintain their highest practicable well-being, were not formally documented or addressed in accordance with facility policy and regulatory requirements.