Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents in key areas, as observed through record reviews, interviews, and direct observation. For one resident with a history of urinary tract infection, end stage renal disease, and schizophrenia, the facility did not create a care plan addressing the resident's smoking habits, despite the resident being assessed for smoking and requiring supervision and a smoking apron. Staff interviews confirmed that the absence of a smoking care plan could result in staff being unaware of the resident's needs and the necessary safety precautions. Another resident with chronic obstructive pulmonary disease, schizophrenia, and bipolar disorder was prescribed Remeron for depression and poor appetite. However, no care plan was developed to address the use of this medication, including monitoring for side effects and meal intake. Staff acknowledged that the care plan should have been created when the medication was ordered, and the lack of such a plan meant that staff would not know what interventions were in place or how to monitor the resident's response to the medication. Additionally, a resident with acute respiratory failure, COPD, and congestive heart failure was prescribed BiPAP therapy at night, but the care plan did not specify the cleaning schedule or duration of therapy. Observations revealed inconsistent cleaning and documentation practices for the BiPAP equipment, and staff interviews confirmed that the care plan lacked necessary details for proper care and infection control. Furthermore, two residents receiving antianxiety and psychotropic medications did not have care plans addressing the use of these drugs, their potential side effects, or monitoring requirements. Staff interviews indicated that the absence of these care plans could lead to unrecognized adverse effects and inconsistent care.