Failure to Implement and Develop Comprehensive Care Plans for Dental, Skin, and PTSD Needs
Penalty
Summary
The facility failed to provide necessary dental services to a resident who was admitted with moderate protein-calorie malnutrition, stroke history, failure to thrive, and legal blindness. Despite being covered under Medicaid and having a care plan that included dental evaluation and treatment, there was no evidence in the medical record that the resident had been seen by a dentist since admission. The resident expressed interest in obtaining new dentures, as his lower dentures were broken and not present at the facility, but no attempts to arrange dental services or replace the dentures were documented. Staff interviews confirmed a lack of awareness regarding the resident's denture status and the absence of dental care provided. Another resident, with a history of stroke, muscle weakness, and impaired mobility, was identified as being at risk for pressure ulcers. The care plan included interventions to offload the resident's heels to prevent skin breakdown. However, multiple observations revealed that the resident's heels were not offloaded while in bed, and no pillows or devices were used for this purpose. Staff interviews indicated a lack of implementation of the care plan intervention, with CNAs unaware or not following the directive to offload the resident's heels, despite having access to the care plan instructions. A third resident, admitted with multiple diagnoses including PTSD, did not have a care plan or interventions addressing PTSD, despite facility policy requiring trauma-informed care planning. The social worker confirmed that a trauma-informed care observation was not completed upon the resident's readmission, and the diagnosis of PTSD was not addressed in the care plan. This omission was attributed to a lack of awareness of the resident's diagnosis at the time of readmission.