Failure to Develop and Maintain Comprehensive Care Plans for Residents with Pressure Ulcer and Respiratory Risks
Penalty
Summary
The facility failed to develop and maintain comprehensive care plans for two residents with significant medical needs. One resident, who had diagnoses including a right tibia fracture, type 2 diabetes, morbid obesity, and pulmonary embolism, was assessed as being at moderate risk for pressure ulcers according to multiple Braden Scale assessments. Despite this, the resident's care plan did not include a risk for skin breakdown or specific interventions to prevent pressure ulcers, even though the nurse practitioner had recommended a repositioning program and heel protectors. Nursing staff believed that repositioning was part of the care plan, but documentation did not reflect this, and the director of nursing confirmed the absence of a preventive care plan for skin breakdown. Another resident with morbid obesity, chronic pain, reduced mobility, and obstructive sleep apnea was observed using an oxygen concentrator and a non-invasive mechanical ventilator. The care plan for this resident did not address the risk or potential for respiratory system impairment, despite the presence of respiratory equipment and physician orders for a non-invasive ventilator. Additionally, there was no physician order for oxygen, even though the resident had been on oxygen since admission, and the care plan did not address the use of oxygen or other respiratory interventions. The LPN and DON both confirmed the lack of a respiratory care plan for this resident. Facility policy requires that comprehensive, person-centered care plans include measurable objectives, timeframes, and services to maintain residents' highest practicable well-being, and that care plans be revised as residents' conditions change. In both cases, the facility did not ensure that care plans reflected the residents' current needs and risks, as evidenced by the lack of documented interventions for pressure ulcer prevention and respiratory care.