Failure to Develop and Implement Comprehensive, Measurable Care Plans
Penalty
Summary
Surveyors found that the facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for several residents. One resident with schizophrenia, depression, and severe obesity, who was incontinent of bladder and at risk for pressure ulcers, did not have a documented care plan addressing incontinence care or an incontinence schedule, despite frequent episodes of incontinence recorded across all shifts. The Director of Nursing was unable to provide documentation of any interventions or care plan for this resident's incontinence. Another resident with cancer, peripheral vascular disease, and asthma, who required substantial to maximal assistance for activities of daily living (ADLs), did not have an ADL care plan in place until after the survey period, even though the resident was dependent in bed mobility, transfers, and wheelchair mobility. Additionally, a resident with stiff-man syndrome, type 1 diabetes, dysphagia requiring G-tube feedings, and stomach cancer had an incomplete care plan for tube feeding, lacking measurable goals and interventions. Staff interviews revealed gaps in care plan initiation and completion, as well as a lack of documented in-service education for nurse managers and supervisors.