Failure to Develop Comprehensive Care Plans for Resident-Specific Needs
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed the specific needs of three residents. For one resident, there was no care plan created to address the use of bilateral padded side rails and an intravenous (IV) device, despite physician orders for both interventions and repeated observations of their use. Staff interviews confirmed the absence of care plans for these devices, and there was no documentation of the resident or representative's request for the padded side rails in the medical record. Another resident had a physician's order for the application of a sequential compression device to both lower extremities for deep vein thrombosis (DVT) prophylaxis. However, the care plan did not include this intervention. Staff interviews verified that the care plan was missing this essential component, and it was acknowledged that the resident required assessment and a care plan for the device. A review of a closed medical record for a third resident revealed diagnoses of Type 2 diabetes mellitus (DM), diabetic chronic kidney disease, and diabetic ophthalmic complications. The resident had active orders and administration of insulin and oral antidiabetic medications, but there was no care plan developed to address the management of DM or the use of these medications. Staff confirmed the absence of a comprehensive care plan for the resident's diabetes management.