Failure to Individualize and Update Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for several residents, as evidenced by direct observations, staff interviews, and record reviews. For one resident with rectal cancer and chronic diarrhea, the care plan did not address the chronic diarrhea or the resident's refusals of prescribed medications for this condition. Additionally, the same resident required assistance with oral hygiene due to being bedbound and visually impaired, but there was no care plan in place for oral hygiene needs. Another resident, who was cognitively intact, had their bed positioned against the wall, but this intervention was not included in their care plan. Similarly, a resident with chronic heart failure who was receiving a diuretic and had documented edema did not have care plan interventions addressing diuretic use or edema management. A further resident, also cognitively intact and missing natural teeth, did not have this dental issue addressed in their care plan, despite expressing a desire to see a dentist. Additionally, a resident with dementia, depression, anxiety, and muscle weakness had a physician's order for their bed to be placed against the wall to increase environmental space, but this was not reflected in their care plan. Staff interviews confirmed that these omissions were not in line with facility expectations and that the care plans should have included these resident-specific interventions.