Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
Surveyors found that the facility failed to develop and implement comprehensive care plans for two of twelve sampled residents. In the first case, a resident with Alzheimer's disease and severe cognitive impairment was observed using a half bed rail for bed mobility on multiple occasions. Despite facility policy requiring the use of side rails to be addressed in the care plan, the resident's care plan did not document the use of the half side rail. The MDS coordinator confirmed that a care plan related to the use of the half bed rail had not been developed for this resident. In the second case, another resident with congestive heart failure, who was dependent on staff for several activities of daily living and used supplemental oxygen, was observed with an oxygen nasal cannula in place. The resident's care plan did not indicate the level of assistance required for activities of daily living or the use of supplemental oxygen. The MDS coordinator acknowledged that they were unaware of the resident's routine use of supplemental oxygen and had missed developing a care plan for both the oxygen use and the resident's ADL needs.