Failure to Develop and Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement complete, resident-centered care plans for three residents, resulting in staff being unaware of critical care needs and preferences. For one resident with severe cognitive impairment and a preference for communicating in Cambodian, the care plan did not include the need for an interpreter, despite documentation in the Minimum Data Set (MDS) and confirmation from the resident’s emergency contact that he preferred communication in Cambodian. Staff routinely communicated with the resident in English, and there was no evidence that an interpreter was used, leading to potential misunderstandings and frustration for the resident. Two other residents, both with physician orders for oxygen administration, did not have care plans addressing their oxygen therapy. One resident with chronic obstructive pulmonary disease (COPD) and diabetes mellitus was receiving oxygen at two liters per minute via nasal cannula, but no care plan was found outlining the administration, monitoring, or goals for oxygen therapy. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that a care plan was necessary to guide staff in providing safe and effective oxygen therapy, including details such as flow rate, oxygen saturation goals, and potential side effects. Similarly, another resident with heart failure and peripheral vascular disease had an order for oxygen therapy but lacked a corresponding care plan. The DON acknowledged that the absence of a care plan meant staff did not have guidance on the rationale for oxygen use, monitoring requirements, or interventions to ensure safe administration. Facility policy required that care plans be developed from comprehensive assessments, but these were not completed for the residents in question, resulting in staff being uninformed about essential aspects of their care.