Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, resulting in unmet needs related to activities, pain management, edema, and personal hygiene. For one resident with dementia, diabetes, and hypertension, the care plan documented preferences for music and reading, but observations showed the resident was left unengaged at the nurses' station, and staff interviews confirmed that appropriate activities were not consistently offered after a unit transfer. Another resident with fibromyalgia, arthritis, and colon cancer reported daily pain, but the care plan lacked specific pain monitoring interventions, and no pain monitoring documentation was found in the electronic health record. A third resident with back pain, sciatica, and arthritis reported severe pain that was not effectively managed, and although pain medication was administered, there was no care plan addressing pain. Staff confirmed that residents with ongoing pain complaints should have individualized pain care plans, but these were missing. For a resident with chronic kidney disease and edema, observations revealed significant swelling in the lower extremities, yet no care plan was initiated to address edema, contrary to staff expectations for accurate care planning. Additionally, a resident with multiple conditions including intracerebral hemorrhage, chronic kidney disease, and hemiplegia was observed with unshaved facial hair and long nails. The care plan did not specify the level of assistance or frequency for shaving and nail care, nor did it include the resident's preferences. Staff interviews indicated the resident was dependent on staff for these tasks and often refused care, but the lack of care planning for personal hygiene needs did not meet facility expectations.