Failure to Develop and Implement Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for three residents with specific medical needs. One resident with end stage renal disease and dependent on hemodialysis did not have a care plan addressing hemodialysis management, including care of the dialysis access site and dietary restrictions, despite physician orders and staff acknowledgment that such a plan was necessary. The resident was cognitively intact and had clear orders regarding dialysis care, but the care plan did not reflect these needs. Another resident with sensorineural hearing loss and blindness in one eye did not have care plans addressing hearing and vision impairments. Although the resident was cognitively intact and had requested audiology and eye care consultations, and had experienced falls potentially related to these deficits, the care plan did not address these issues. Staff interviews confirmed the absence of appropriate care plans for hearing and vision needs, despite physician orders and resident requests for related services. A third resident, who had severe cognitive deficits, was dependent for all self-care, and at high risk for pressure ulcers, did not have a physician-ordered Prevalon boot applied to the right foot as required. Multiple observations over several days showed the resident was not wearing the boot, and it was not present in the room. Nursing notes did not document any refusal of the device, and staff confirmed the order was active and should have been followed, with refusals documented if applicable.