Failure to Develop and Implement Individualized Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans with measurable objectives, timeframes, and interventions for four residents with diverse and significant medical needs. For one resident receiving Lovenox, an anticoagulant, there was no care plan addressing interventions and goals related to the medication, despite physician orders and administration records confirming its use. The Director of Nursing (DON) acknowledged that a care plan was necessary for anticoagulant therapy to guide staff in monitoring for adverse effects such as bleeding and to provide appropriate interventions in emergencies, but no such plan was present. Another resident with impaired immunity due to a viral infection, specifically HIV, had a care plan that included monitoring for delirium as an intervention. However, there was no evidence that staff were monitoring or documenting signs and symptoms of delirium as required. The DON confirmed that the care plan did not specify the frequency of monitoring or documentation, and that this monitoring was not being performed, despite its importance in preventing complications related to immune deficiency. A third resident with severe vision impairment due to glaucoma and diabetes had no care plan addressing their specific activity needs. The DON stated there was no coordination with the activity director to develop a plan tailored to the resident's visual impairment, which could lead to isolation or behavioral issues. Additionally, a fourth resident with diabetes and chronic kidney disease did not have a care plan addressing their nutritional needs, including interventions for monitoring food brought from outside the facility. The dietary supervisor and DON both confirmed the absence of a care plan for this resident's therapeutic diet, despite the risk of noncompliance with dietary restrictions.