Failure to Develop and Implement Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans that addressed the identified needs of two residents. For one resident with diagnoses including end stage renal disease, diabetes, heart failure, and bladder dysfunction, the care plan did not include interventions for elimination status, specifically omitting catheter care and bowel incontinence management, despite the resident having an indwelling catheter and frequent bowel incontinence. Interviews with facility staff confirmed that such interventions should have been present in the care plan and linked to aide documentation tasks, but were not. For another resident with a history of encephalopathy, weakness, dementia, and a previous fall resulting in a fractured ankle, the care plan lacked interventions for fall risk, even though fall risk assessments consistently indicated a moderate risk. The only fall-related care plan was marked as resolved after the previous fall, and no new interventions were documented despite ongoing risk. Staff interviews confirmed that care plan interventions for fall prevention should have been included, and facility policy required identification and documentation of fall risk factors and implementation of preventive interventions.