Failure to Develop Individualized and Comprehensive Care Plans for Pain and Wound Management
Penalty
Summary
The facility failed to develop individualized and comprehensive care plans for two residents with needs related to pain and wound management. For one resident with diagnoses including malignant neoplasm of the prostate, chronic pain syndrome, and anxiety, the care plan did not clearly identify the presence of pain, lacked individualized details on pain assessment, did not specify a goal for pain tolerance, and omitted how pain impacted sleep, activities of daily living, leisure activities, mood, or behavior. Provider orders included scheduled and as-needed morphine, but there were no documented non-pharmacologic interventions. Interviews revealed that non-pharmacologic strategies were not consistently implemented or documented, and the care plan was not updated to reflect the resident's specific pain symptoms and interventions. For another resident with bilateral lower extremity cellulitis, thoracic spine pain, and chronic pulmonary edema, the care plan identified a general problem with skin integrity but did not specify the presence of venous stasis or pressure ulcers. The interventions listed were generic and did not include individualized instructions for positioning, a turning and repositioning program, or coordination with the outside wound care provider, despite provider orders and documentation indicating the need for these measures. Interviews with nursing staff confirmed the importance of individualized positioning and turning for this resident, but the care plan did not reflect these needs.