Failure to Develop Individualized Care Plans Addressing Resident Needs
Penalty
Summary
The facility failed to develop individualized care plans that addressed all identified needs for three residents. For one resident with diabetes on a mechanically altered, therapeutic diet, the care plan did not include any information or interventions related to nutritional needs, despite the resident expressing dissatisfaction with food choices and not being offered a night snack. The dietician confirmed that the care plan lacked necessary details regarding the resident's nutritional status. Another resident, who was alert and oriented and frequently incontinent of urine and bowel, did not have any interventions or information related to incontinence included in the care plan, as confirmed by the nursing home administrator. Additionally, a third resident with a hiatal hernia had specific dietary restrictions and requests documented in nursing notes, but the care plan did not reflect these needs. The director of nursing confirmed the omission of information regarding the hiatal hernia in the care plan.