Failure to Develop and Implement Comprehensive Care Plans for Specialized Medical Devices
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for two out of five sampled residents. For one resident with diagnoses including Type 2 diabetes mellitus, chronic kidney disease, morbid obesity, congestive heart failure, generalized edema, and dependence on renal dialysis, the care plan did not address the presence or care of an indwelling urinary catheter or a right chest wall dialysis access site. This omission was confirmed through record review, observation, and staff interview, despite the resident being cognitively intact and able to report the presence of these devices. Another resident, admitted with hemiplegia and hemiparesis following cerebrovascular disease, acute and chronic respiratory failure, moderate protein-calorie malnutrition, and a gastrostomy, was observed to have a PEG tube. However, the comprehensive care plan did not include any problems, goals, or approaches for PEG tube care. This deficiency was confirmed by both observation and staff interview, as the resident's care plan lacked documentation for the required care of the feeding tube.