Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three of eight residents reviewed. For one resident with diagnoses of diabetes and bipolar disorder, the care plan did not include goals or interventions related to the use of prescribed antidepressant and antipsychotic medications, despite multiple physician orders for these medications. Another resident, admitted with pressure ulcers on both heels and diagnosed with metabolic encephalopathy and muscle weakness, had a care plan that addressed only the risk of developing skin integrity issues, but did not include a plan of care with goals and interventions for the actual presence of a Stage III pressure ulcer. A third resident, with osteoporosis, muscle weakness, and hypercalcemia, was observed self-administering medication but did not have a care plan addressing self-administration of medication, despite being cognitively intact and reporting difficulty swallowing pills. The Nursing Home Administrator and Director of Nursing confirmed that comprehensive care plans addressing all resident care needs were not completed for these residents, as required by facility policy and state regulations.