Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required. For one resident with a history of high blood pressure, diabetes, kidney failure, and dementia, the care plan did not include any dietary orders or interventions, despite the resident being underweight and receiving a fortified diet and nutritional supplements. Observations and interviews confirmed that the resident was frail and underweight, and that interventions were in place and effective, but these were not documented in the care plan as required by facility policy. For two other residents with a diagnosis of hypertension, their care plans did not document goals or interventions related to blood pressure management, even though both were prescribed antihypertensive medications. Medical records showed that these residents had active diagnoses of hypertension and were receiving medications such as Amlodipine, Carvedilol, and Losartan. However, the care plans lacked any mention of hypertension management, goals, or interventions. Interviews with facility staff, including the MDS nurse and DON, revealed that the omission of dietary interventions and hypertension management from the care plans was an oversight. Staff acknowledged that care plans should include all relevant diagnoses and interventions to guide care, and that the absence of this information could result in staff not being aware of the residents' needs.