Failure to Develop Care Plan for Alcohol Use
Penalty
Summary
A deficiency occurred when the facility failed to develop a person-centered care plan addressing alcohol consumption for a resident. The resident, who was alert and oriented with a BIMS score of 14, had diagnoses including chronic diastolic congestive heart failure, cellulitis of the left lower limb, and acute kidney failure. Despite requiring some assistance with ADLs, there were no physician orders or care plan interventions related to alcohol use documented in the resident's medical record. Observations revealed that the resident had two bottles of alcoholic beverages stored in his compact refrigerator, which were purchased by a friend for his consumption. The facility's policy required that alcoholic beverages be prescribed by a provider, obtained by family, and administered only by a licensed nurse, with residents not permitted to keep alcohol in their rooms. The Administrator and Regional Registered Nurse confirmed the presence and removal of the alcohol, and acknowledged the absence of appropriate orders or a care plan for alcohol use.