Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by policy. For one resident with chronic pulmonary disease and respiratory failure, there was a physician order for weekly nebulizer mask and tubing changes, but the care plan did not address nebulizer treatments. The resident reported issues with the nebulizer, and the assistant director of nursing confirmed the absence of a related care plan. Another resident with Parkinson's disease and syncope had physician orders for continuous and as-needed oxygen administration, but the care plan lacked any focus, interventions, or goals related to oxygen therapy, as confirmed by a registered nurse. A third resident, admitted with pressure ulcers and at risk for further injury, had a physician order for PR boots to be worn in bed to elevate the heels. The resident was observed not wearing the boots and stated noncompliance, while documentation from the wound team noted this noncompliance. However, the treatment administration record inaccurately documented the resident as compliant, and the care plan did not address the use of boots or the resident's noncompliance. These findings were based on policy review, clinical record review, observations, and staff interviews.