Failure to Develop Comprehensive Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents with specific needs. For one male resident with multiple diagnoses including hemiplegia, dysphagia, and a gastrostomy, the care plan did not address the presence or management of the gastrostomy tube, despite documentation in the Minimum Data Set and physician orders indicating its use for water administration. The care plan only referenced dietary restrictions and dysphagia, omitting any interventions or monitoring related to the gastrostomy tube. The Director of Nursing confirmed that a care plan for the gastrostomy tube was missing, even though it was required. For a female resident with diagnoses including monoplegia, dysphagia, and cognitive impairment, the facility did not initiate a discharge care plan upon admission, as required by facility policy. The Director of Nursing acknowledged that discharge planning should begin at admission and be updated as needed, but there was no evidence of a discharge care plan being developed for this resident. The facility's policy mandates that a comprehensive care plan, including discharge planning, be developed within seven days of the comprehensive assessment, but this was not followed.