Failure to Develop and Implement Individualized Care Plans for Medication and Dental Needs
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents, resulting in deficiencies related to medication management and dental care. For one resident with atrial fibrillation who was prescribed apixaban, there was no care plan developed to address the use of this anticoagulant, despite documentation confirming the medication was being administered as ordered. Staff interviews confirmed the absence of a care plan and acknowledged the necessity of such a plan to guide monitoring and care. Another resident, who was cognitively intact and had both upper and lower dentures upon admission, experienced the loss of their dentures while at the facility. Despite dental assessments, recommendations for tooth extraction, and ongoing issues with eating and appearance, there was no care plan developed to address the resident's dental care needs. Staff and social services confirmed awareness of the dental issues and the lack of a corresponding care plan. A third resident, with a history of stroke and on anticoagulant therapy (Lovenox), had a care plan that included interventions for daily skin inspections and monitoring for complications such as bruising. However, after the resident sustained a fall and developed bruising, there was no evidence that the care plan interventions were implemented, as required. The DON confirmed that the resident's bruising should have been monitored according to the care plan, but this was not documented or carried out.