Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as required by policy. For one resident with diagnoses including dysphagia, generalized anxiety disorder, and cerebral infarction, the care plan did not address the use of Ambien, a hypnotic medication, despite a physician's order for its use and documentation that the resident received the medication. The resident was cognitively intact and required staff assistance with activities of daily living. The Director of Nursing confirmed that a care plan for the use of Ambien had not been initiated. For another resident with benign prostatic hyperplasia, chronic kidney disease, and unspecified intellectual disabilities, the care plan did not address the resident's edentulous status, even though the resident was observed and confirmed to be edentulous upon admission. The admission MDS assessment did not correctly code the resident's dental status, and the dental care plan failed to include interventions specific to being edentulous. The MDS Registered Nurse confirmed these omissions during an interview.