Failure to Develop and Implement Accurate Care Plans
Penalty
Summary
The facility failed to ensure that care plans were accurate and comprehensive for four residents out of 23 reviewed. Specifically, residents with significant medical conditions such as diabetes, chronic ulcers, osteomyelitis, pulmonary hypertension, dementia, and those on hospice care did not have appropriate care plans addressing their current needs. For three residents with documented pressure ulcers or wounds, there was no corresponding care plan in place to address wound care, despite medical records and wound center documentation confirming the presence of these conditions. In one case, a care plan for a pressure wound was only created after the issue was identified during the survey. Additionally, a resident admitted to hospice care with severe cognitive impairment and a diagnosis of senile degeneration of the brain did not have any goals or interventions documented in the care plan related to hospice care. Staff interviews confirmed the absence of these required care plans. The facility's own policy mandates the development and implementation of comprehensive, person-centered care plans with measurable objectives and time frames to meet residents' medical needs, which was not followed in these cases.