Failure to Develop Comprehensive Care Plans for Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address the specific needs and conditions of several residents, as required by regulation. For one resident with multiple complex diagnoses, including metabolic encephalopathy, cerebrovascular accident, and acute respiratory failure, there was no care plan addressing the use of continuous oxygen therapy, despite physician orders and direct observation confirming ongoing oxygen use. The resident's Minimum Data Set (MDS) assessment also did not reflect oxygen use, and nursing staff confirmed the absence of a care plan for this intervention. Another resident with diagnoses such as acute respiratory failure, cerebral infarct, and obstructive sleep apnea was observed using a Bi-pap device with oxygen, and physician orders specified continuous oxygen therapy and related care. However, there was no care plan in place to address the resident's oxygen use, and the MDS assessment did not indicate oxygen therapy, despite documentation and observation to the contrary. Nursing staff confirmed the lack of a care plan for this resident's oxygen therapy. A third resident with a history of constipation, anemia, and contractures had active physician orders and was receiving medications for constipation and anemia, but there was no care plan addressing these conditions or the resident's significant upper extremity functional limitations and contractures. Additionally, a fourth resident with multiple psychiatric diagnoses and an order for nightly Melatonin for insomnia did not have a care plan addressing insomnia or the use of Melatonin, despite the order being in place for an extended period. Nursing staff responsible for care planning confirmed the absence of required care plans for these residents.