Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to implement and develop comprehensive, individualized care plans for several residents in key areas, as observed and documented by surveyors. One resident with severe cognitive impairment and functional limitations was dependent on staff for all transfers and mobility, with a care plan specifying daily use of a Geri chair. Despite this, repeated observations over several days showed the resident remained in bed, and staff interviews revealed that nurse aides either did not follow the care plan, were unaware of its requirements, or did not prioritize the intervention due to other tasks or lack of equipment in the room. The resident's responsible party confirmed that the resident was not regularly assisted into the Geri chair as intended. Another resident with a PEG feeding tube had a physician's order for regular tube flushes and received a significant portion of daily fluid intake via the tube. However, the care plan did not address the use of the feeding tube, despite the Minimum Data Set (MDS) assessment triggering a Care Area Assessment (CAA) for feeding tube use. Both the dietary manager and the DON acknowledged that the feeding tube should have been included in the care plan, but it was omitted without explanation. Additionally, two residents using noninvasive mechanical ventilators (BiPAP and CPAP machines) for respiratory conditions did not have their device usage reflected in their care plans. In both cases, the residents were observed using the devices, and staff confirmed their ongoing use. However, there were no corresponding physician orders or care plan interventions for these devices. MDS nurses responsible for care planning admitted to missing these interventions, either due to reliance on memory or because the care planning system did not automatically prompt for respiratory care based on MDS coding. The DON and administrator confirmed that these omissions were contrary to expected practice.