Failure to Implement and Follow Resident Care Plans
Penalty
Summary
Staff failed to implement care plans for two residents. For one resident with documented combative behaviors, the care plan included referral to behavioral health services as recommended by the nurse practitioner. However, there was no documentation of mental health services being provided for the last four months, and interviews with the social worker, RN, DON, and administrator confirmed that the resident had not been referred or evaluated by behavioral health services as required by the care plan. For another resident with a history of shortness of breath, acute respiratory failure, COPD, and lung neoplasm, the care plan required administration of oxygen therapy at three liters per minute (LPM) via nasal cannula, as ordered by the physician. Observations revealed the resident was receiving oxygen at only two LPM on multiple occasions. The MDS Coordinator and DON confirmed that staff failed to follow the care plan and physician's orders regarding oxygen administration.