Failure to Implement and Document Care Plan Interventions for Two Residents
Penalty
Summary
Facility staff failed to implement parts of comprehensive care plans for two residents, as identified during a complaint survey. For one resident with quadriplegia, a recent gastrostomy tube placement, and contractures, the care plan included specific nursing interventions such as checking the feeding tube for placement and gastric residuals and recording the results. However, a review of medication and treatment administration records over several months showed that nursing staff did not document these required checks and recordings, indicating that this aspect of the care plan was not followed. For another resident with dementia, congestive heart failure, COPD, diabetes, and nutritional risk, the care plan required staff to notify the nurse if the resident consumed less than 50% of a meal. Meal intake records revealed that the resident ate less than half of their meals on 34 occasions over nearly a month, but there was no documentation that the nurse was notified as required by the care plan. These findings demonstrate that staff did not consistently implement or document key interventions outlined in the residents' individualized care plans.