Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with Parkinson's disease, dementia, and anxiety disorder, the care plan included the use of antianxiety medications but did not document any non-pharmacological interventions for anxiety, mood, or behavior. The resident had severely impaired cognition and was prescribed multiple psychotropic medications, including alprazolam, buspirone, and trazodone, all for anxiety disorder. The care plan did not mention trazodone or outline any non-pharmaceutical approaches, and this omission was confirmed by the Director of Nursing. For another resident with Alzheimer's disease, congestive heart failure (CHF), atrial fibrillation, diabetes, and a history of stroke, the care plan did not address several significant medical conditions or the use of high-risk medications. The resident was taking an antiplatelet and a diuretic, but the care plan lacked problem areas or interventions related to diabetes, CHF, antiplatelet, or diuretic use. This gap was confirmed by both the Nursing Home Administrator and the Director of Nursing, who acknowledged that these areas should have been included in the care plan. The facility's own policy requires that care plans address all problem areas identified through assessments, including measurable goals and approaches for each issue. In both cases, the care plans did not meet these requirements, as they failed to include all relevant diagnoses, medications, and necessary interventions, resulting in incomplete documentation and planning for the residents' care needs.