Failure to Develop and Implement Comprehensive Care Plans for Medications and Respiratory Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents in accordance with its own policies and procedures. For two residents with mood and behavioral concerns, there was no care plan created for the use of prescribed antidepressant and anxiolytic medications (trazodone and alprazolam). In both cases, staff interviews confirmed that care plans were not in place to guide the safe administration and monitoring of these psychoactive medications, despite facility policy requiring such plans to be developed within a specified timeframe after assessment. Additionally, a resident receiving intravenous antibiotic therapy (Cefepime HCl) for osteomyelitis did not have a care plan in place for the medication until after the deficiency was identified by surveyors. The care plan was only created after the issue was brought to staff attention, indicating a delay in the development and implementation of a care plan for this resident's antibiotic use. This was confirmed by both the reviewing nurse and the DON, who acknowledged the absence of a timely care plan. A further deficiency was identified for a resident with obstructive sleep apnea and a physician order for nightly CPAP therapy. Despite the resident's history of noncompliance with CPAP use, there was no care plan developed to address the use of the device or interventions for refusal. Staff interviews confirmed that a care plan should have been in place since admission to address CPAP administration and noncompliance, but none was found in the resident's record. Facility policy required baseline and comprehensive care plans to be developed and updated as needed, but this was not followed in these cases.