Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for four residents with specific and documented care needs. For one resident, observations revealed significant foot issues, including dry, flaky skin, red and swollen toes, thick and discolored toenails, and wounds, yet there was no care plan addressing foot care. Another resident with a history of respiratory disorders and acute respiratory failure with hypoxia did not have an individualized care plan for managing their respiratory condition. In both cases, staff interviews and record reviews confirmed the absence of appropriate care plans. Additionally, two residents with peripheral intravenous (IV) lines did not have individualized care plans for IV site care and management. One resident had an IV inserted with orders to change the site every 96 hours, but the site was never changed, and no care plan was in place. The other resident was observed with an IV and a gauze dressing, but again, no documented care plan was found. Review of the facility's own policy confirmed the requirement for comprehensive, person-centered care plans with measurable objectives and timetables, which was not met for these residents.