Failure to Implement and Document Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement and follow individualized care plans for two residents with complex medical needs. For one resident with a history of liver transplant, chronic kidney disease, and major depressive disorder, daily weights were ordered to monitor for signs of liver rejection and kidney function changes. However, the resident was not weighed daily as ordered, and when weights were obtained, they were not performed consistently in the same manner or at the same time of day. Documentation showed that the resident refused weights on 17 days, but there was no evidence that the provider or transplant coordinator was notified of these refusals, as required by the care plan and facility policy. Multiple staff interviews confirmed that provider notification was expected after repeated refusals, but this did not occur. For another resident with congestive heart failure (CHF) and atrial fibrillation, the care plan included daily weights and the application of compression garments to manage fluid retention and monitor for CHF exacerbation. The resident's medical record indicated that weights frequently exceeded the threshold requiring provider notification, but there was no documentation that the provider was informed. Observations revealed that compression wraps were not consistently applied in the morning as ordered, and the resident was often seen with swollen feet and without the prescribed wraps. Staff interviews confirmed knowledge of the care plan requirements but acknowledged that time constraints and other factors led to inconsistent implementation. Facility policy required timely provider notification and documentation of significant weight changes or refusals of care. Despite this, both residents' records lacked evidence of appropriate provider notification and consistent implementation of ordered interventions. The deficiency was identified through observation, record review, and staff interviews, all of which demonstrated a failure to follow individualized care plans and provider orders for residents with significant health risks.