Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing the medical and nursing needs of two residents. For one resident with diagnoses including type 2 diabetes mellitus, chronic kidney disease stage 3b, and edema, there was no care plan in place to monitor for adverse reactions or efficacy related to the administration of diuretic medications, despite the resident receiving furosemide and exhibiting significant edema and mobility difficulties. The absence of a care plan was confirmed through record review and interviews, with the Director of Nursing acknowledging the oversight. For another resident with multiple complex diagnoses, including Alzheimer's disease, dementia, and severe cognitive impairment, who was receiving hospice services, the facility did not develop a hospice or end-of-life care plan. This was confirmed through review of the resident's care plans and direct inquiry with the Nursing Home Administrator, who indicated that no hospice care plan had been created. These deficiencies were identified through observation, interview, and record review.