Failure to Develop Comprehensive Care Plan for Edema and Compression Stockings
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with edema and an order for compression stockings. Record review showed that the resident, an elderly male with severe cognitive impairment and diagnoses including edema and high blood pressure, did not have his edema or the use of compression stockings addressed in his care plan, despite these needs being identified in his assessment. The care plan dated after the assessment did not include interventions or measurable objectives related to these conditions. Interviews with the ADON and the Interim DON confirmed that it was the responsibility of nursing management to update care plans when new orders were received. The ADON acknowledged missing the orders and not updating the care plan, which could result in not taking appropriate measures to address the resident's edema. The Interim DON also recognized the omission but did not perceive a risk as long as nurses followed the doctor's orders. The facility's policy requires a person-centered care plan to address all medical, physical, mental, and psychosocial needs, which was not followed in this case.