Failure to Develop and Implement Individualized Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, implement, and individualize comprehensive care plans for five residents, resulting in deficiencies in meeting their specific care needs. For one resident with spinal stenosis and recent back surgery, the care plan for pain management was incomplete and not individualized, with many blank areas and lacking resident-specific information. Nursing staff did not consistently document pre- and post-medication pain assessments or the effectiveness of PRN pain medication, despite the resident receiving multiple doses. The medication administration record was not properly updated, and the effectiveness of pain interventions was not monitored as required by the care plan and facility policy. Two residents receiving antipsychotic medication (Seroquel) did not have care plans that identified the targeted behaviors, specific interventions, or measurable goals for the use of these medications. In both cases, staff and family interviews indicated that the residents did not exhibit the behaviors typically associated with the use of antipsychotics, and the care plans failed to include non-pharmacological interventions or rationale for the medication. The care plans were generic and did not reflect the residents' actual needs or conditions, and one resident's use of antipsychotic medication was not care planned at all. Additionally, after a resident sustained a fall, the facility did not implement or document any new interventions to minimize future falls, contrary to facility policy. Another resident using continuous oxygen therapy did not have a care plan addressing oxygen use, despite physician orders and the resident's significant cognitive impairment and respiratory needs. In each case, the lack of individualized, comprehensive care planning and failure to implement or document required interventions led to deficiencies in the facility's care delivery process.