Failure to Develop and Implement Comprehensive Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific needs. For one resident who was identified as a smoker with intact cognition, the care plan specified that cigarettes and a lighter should be stored at the nurse's station. However, observation revealed the resident kept the lighter in her pocket after smoking, and staff interviews indicated inconsistency in the storage of smoking materials, with some staff stating items should be kept in room lockboxes instead. The Director of Nursing expected the lighter to be stored at the nurse's station, but this was not consistently followed. For another resident with moderately impaired cognition and a history of depression, anxiety, and dementia, the care plan addressed antidepressant use but did not include documentation or interventions for suicidal ideation, despite a recent incident where the resident expressed a desire to kill herself and was sent to the emergency room for evaluation. Upon return, new medication orders were implemented, but the care plan was not updated to reflect interventions for suicidal ideation. The Director of Nursing confirmed that the care plan was not implemented for the interventions related to the resident's suicidal ideation.