Failure to Develop Care Plan for Resident with Liver Transplant
Penalty
Summary
The facility failed to develop a care plan addressing a resident's history of liver transplant. Review of the resident's admission record showed multiple complex diagnoses, including paranoid schizophrenia, anemia, diabetes mellitus, major depressive disorder, kidney transplant, and liver transplant. The resident was noted to be cognitively intact but required varying levels of assistance with activities of daily living. Despite these complexities, there was no care plan specific to the liver transplant documented in the resident's records. During an interview and record review with the DON, it was confirmed that a care plan for the liver transplant was missing, and the DON acknowledged that such a plan should have been in place to guide staff in providing appropriate care. The facility's policy and procedures require a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident, but this was not followed for the resident with a liver transplant.