Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified care needs for two residents. For one resident with diagnoses including anemia, hypertension, and Parkinson's Disease, the clinical record showed active physician orders for antidepressant and sedative/hypnotic medications. However, the resident's care plan did not include goals or interventions related to the use of these medications. This omission was confirmed by the Director of Nursing during an interview. For another resident with difficulty swallowing, vitamin deficiency, and Alzheimer's disease, the clinical record included a physician order for daily application of bilateral lower knee TED hose due to peripheral vascular disease. The care plan for this resident did not reflect the use of TED hose as ordered. This was confirmed by the Registered Nurse Assessment Coordinator. These findings demonstrate that the facility did not ensure care plans were comprehensive and addressed all current physician orders and resident needs as required by facility policy and state regulations.