Failure to Develop and Implement Required Care Plans and Interventions
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents as required. For one resident with a history of major depressive disorder, opioid abuse, PTSD, and alcoholic cirrhosis, the care plan did not address substance use disorders. The resident's social service history and evaluation documented alcohol and opioid abuse, but the care plan lacked interventions, triggers, or support plans for these issues. The social worker confirmed that care plans for alcohol and opioid abuse should have been developed for this resident. For another resident with diagnoses including Type 2 Diabetes Mellitus, myxedema coma, bipolar disorder, and depression, the facility failed to implement physician-ordered geri-sleeves to the resident's arms and legs. Multiple observations over several days showed the resident was not wearing the required geri-sleeves, and there was no documentation of refusal in the nursing notes. Interviews with nursing staff revealed a lack of awareness of the order, and the resident reported not having worn the sleeves for about a month. The administrator stated that the expectation was for the sleeves to be worn as ordered and refusals to be documented.