Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement complete care plans for three residents, as identified during a Medicare/Medicaid recertification and complaint survey. One resident was admitted with a history of epilepsy, hemiplegia, and hemiparesis, and had both a stage 2 pressure wound and a venous wound documented by the wound team. Despite these findings, there was no care plan in place addressing the management of the resident's wounds. Interviews with the Unit Manager and DON confirmed that a wound care plan should have been created but was not present in the resident's record. Another resident with a terminal prognosis was admitted to hospice care, but the facility did not initiate a hospice care plan. The Unit Manager and DON both acknowledged the absence of a hospice care plan for this resident. Additionally, a third resident was receiving antipsychotic and antidepressant medications for depression and bipolar disorder, but the care plan did not include any focus, goals, or interventions related to these medications. The DON confirmed that a comprehensive care plan addressing the use of these medications was not developed or implemented.