Failure to Maintain Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to maintain comprehensive, resident-centered care plans for three residents, as evidenced by incomplete or missing documentation and care planning for significant medical needs. For one resident with a PICC line for antibiotic therapy, the care plan did not specify the type of intravenous access or provide complete information regarding the IV status, despite orders and ongoing treatment. The Director of Nursing confirmed the care plan was incomplete in this regard. Another resident was admitted with an indwelling urinary catheter, but there was no care plan addressing catheter care, and staff interviews revealed confusion about whether the catheter had been removed. The resident continued to have the catheter in place, as observed by surveyors, but this was not reflected in the care plan or physician orders, and staff were unaware of the ongoing need for catheter care. A third resident with a history of acute respiratory failure, traumatic brain injury, tracheostomy, and severe malnutrition had broken and missing teeth, but the care plan did not address oral or dental status. Staff confirmed that oral care was provided and that the resident had significant dental issues, but there was no care plan in place to address these needs. The facility's policy requires comprehensive, person-centered care plans to be developed within seven days of the MDS assessment, including measurable objectives and timeframes, but this was not followed for the residents reviewed.