Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents whose nursing needs were identified in their comprehensive assessments. For one resident, who was observed wearing a cardiac Life Vest, there were no physician orders for the device and no mention of the Life Vest in the resident's cardiac care plan. The Director of Nursing confirmed that the cardiac care plan should have included the Life Vest, but it was omitted. For another resident with a recent hospitalization for acute chronic respiratory infection, the care plan did not address the infection or the prescribed antibiotic therapy, despite physician orders for antibiotics and diagnoses of acute respiratory failure with hypoxia and pneumonia due to methicillin-resistant Staphylococcus aureus. The MDS also indicated infection and antibiotic use, but the RN/MDS coordinator acknowledged that a care plan for infection was missed.