Failure to Develop Comprehensive Care Plans for Multiple Residents
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans (CPs) that addressed all identified care needs for four residents. For one resident with a history of spinal cord dysfunction, spinal stenosis, and a recent total knee replacement, the CPs did not include the resident's right knee pain or the need to keep the knee straight for healing, despite the resident reporting ongoing pain and limited mobility due to the surgery. Staff interviews confirmed that the knee pain and related interventions were omitted from the CP, which should have included these details for appropriate pain management and therapy. Another resident with fractures in both shoulders had a CP that only addressed the right shoulder fracture, even though medical records and care conference notes documented fractures in both shoulders. The resident required slings on both arms and needed staff to exercise caution during transfers and showers. Staff confirmed that the left shoulder fracture and necessary precautions were not included in the CP, despite the resident experiencing pain in both shoulders and requiring similar interventions for each. Additionally, two other residents with complex medical conditions did not have CPs developed for specific diagnoses being actively treated. One resident receiving medication for gout did not have a CP addressing gout management, including signs, symptoms, and interventions for acute episodes. Another resident with GERD and a physician's order for a proton-pump inhibitor lacked a CP for GERD and related medication use. Staff interviews confirmed that CPs for these conditions were missing, contrary to facility policy requiring CPs for each diagnosis or condition under treatment.