Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two of twenty sampled residents. For one resident with kidney failure and dementia, who was observed to have a contracted right hand and was totally dependent on staff for care, the care plan did not include any interventions for the hand contracture. Staff reported that hand rolls were sometimes used, but there were no formal interventions documented or consistently implemented. The resident's assessment indicated intact cognition and a range of motion impairment, yet the care plan lacked specific measures to address this issue. For another resident with obstructive and reflux uropathy and retention of urine, who had an indwelling urinary catheter and moderate cognitive impairment, the care plan did not include the use of the catheter. The resident's significant change assessment documented the presence of the catheter, but this was not reflected in the care plan. The MDS coordinator confirmed that the care plan should have included interventions related to the urinary catheter, but this was not done.