Failure to Develop Care Plans for Pain, Infection, and Precautions
Penalty
Summary
The facility failed to develop and implement complete care plans to address all identified needs for two residents. For one resident with a significant cognitive impairment and a diagnosis of wedge compression fracture of the lumbar vertebra, medical records showed active physician orders for pain management, including diclofenac sodium gel and Tylenol. However, review of the resident's care plan revealed no documentation or plan for pain management or treatment. The Director of Nursing confirmed the absence of a pain care plan for this resident. Another resident, admitted with a diagnosis of pneumonia and mild cognitive impairment, was placed on enhanced barrier precautions and prescribed a course of Levaquin for seven days. Despite these interventions, there were no care plans developed or initiated for either antibiotic use or enhanced barrier precautions. The Director of Nursing confirmed that care plans for these areas were not in place for this resident.