Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Four residents experienced deficiencies in care planning and implementation. For one resident with Type 2 Diabetes Mellitus, multiple blood sugar readings above 350 mg/dl were recorded over several days, but there was no documentation that the physician was notified as required by the facility's policy. Licensed nurses admitted to not always documenting physician notifications, and the Director of Nursing confirmed that if notification was not documented, it was considered not to have occurred. Another resident with a history of hemiplegia and contractures was using a palm guard splint on the left hand. Staff, including CNAs and licensed nurses, were unaware of the care requirements for the splint, and there was no care plan in place for its use or monitoring. The care plan was only updated after the issue was identified, and staff interviews revealed that the splint had been used for months without proper orders or documentation, potentially leading to improper care. A third resident with Parkinson's Disease, dysphagia, and a history of stroke required supervision during meals due to aspiration risk. Observations showed the resident eating alone and experiencing choking episodes without staff present. Although staff recognized the need for supervision, there was no care plan addressing aspiration precautions or meal supervision. Additionally, a fourth resident with peripheral vascular disease and diabetes had a care plan for podiatry care that was not followed, as the resident had not received podiatry services as scheduled, resulting in long, thick toenails and dry, cracked feet.