Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents, resulting in deficiencies in meeting their individualized care needs. For one resident, the care plan was not updated after droplet isolation precautions for influenza were discontinued. Despite the resident no longer requiring isolation or a single room, the care plan continued to reflect outdated precautions, and staff interviews confirmed that the care plan should have been revised to accurately reflect the resident's current status. The facility's own policies and staff statements indicated that care plans must be updated as residents' conditions change, but this was not done in this case. Another resident was prescribed and administered divalproex for migraine headaches, but there was no care plan addressing the use of this medication or the associated diagnosis. Staff interviews revealed that a care plan should have been initiated for new medications and diagnoses to guide nursing staff in providing appropriate care. The absence of a care plan for this medication meant that staff lacked direction for monitoring and managing the resident's needs related to the new treatment. A third resident was receiving oxycodone for back pain, but the care plan did not include any interventions for the use of this high-risk pain medication. Staff acknowledged that oxycodone requires specific care planning due to its potential side effects, such as respiratory depression and constipation. Additionally, a fourth resident who required continuous oxygen therapy and also smoked did not have an individualized care plan that addressed the interaction between oxygen use and smoking. Staff interviews confirmed that the care plan lacked instructions for managing oxygen therapy during smoking, which was necessary for the resident's safety. In all cases, the facility did not follow its own policies and procedures for developing and updating comprehensive, person-centered care plans based on residents' current needs and conditions.