Failure to Develop and Implement Complete Care Plans for Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans for two residents included all necessary goals and interventions to address their total care needs. For one resident with multiple diagnoses including COPD, diabetes with neuropathy, chronic pain, atrial fibrillation, gout, depression, psychosis, and mild cognitive impairment, the care plan documented a history of refusal of care, such as refusing showers, getting out of bed, ancillary services, and removing a Dexcom sensor. However, the care plan did not include any goals or interventions to address these refusal behaviors, and there were no updates or edits related to interventions or desired outcomes for this problem, despite multiple revisions to the care plan over time. This omission was confirmed by the MDS Coordinator during an interview and was not in accordance with the facility's care planning policy, which requires care plans to be specific to each resident's needs and to include measurable goals and interventions. For another resident with diagnoses including acute on chronic diastolic CHF, respiratory failure, depression, COPD, osteoarthritis, kidney neoplasm, SIRS, muscle spasms, contractures, and constipation, the care plan did not address opioid use, despite the resident being on a scheduled pain regimen and receiving opioids. The care plan noted altered comfort related to various conditions but did not include goals or interventions for monitoring or reporting adverse effects of opioid use. The DON confirmed that such interventions should have been included. The facility's policy requires care plans to be based on comprehensive assessment data and to be reviewed and updated regularly, but these requirements were not met for these two residents.