Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents, resulting in unmet care needs. One resident, admitted with orthopedic aftercare and at high risk for constipation due to pain medication and immobility, experienced ongoing abdominal discomfort and bloating. Despite physician orders for a bowel regimen including Docusate Sodium, Lactulose, and a mineral oil enema if needed, the care plan for constipation was not developed, and not all physician-ordered interventions were administered. Staff interviews confirmed the absence of a care plan and inconsistent application of the bowel protocol, leading to the resident's continued discomfort. Another resident, admitted with fractures to the right tibia and patella and identified as a high fall risk, did not have the physician-ordered intervention of a knee immobilizer included in the care plan. The resident subsequently fell while using the bedside commode without the immobilizer in place, resulting in a fractured left wrist. Staff interviews revealed that the knee immobilizer, which was ordered to be worn whenever the resident was out of bed, was not applied during the transfer, and the care plan did not reflect this critical intervention. Facility policies on bowel care management and fall management required individualized care plans with measurable objectives and interventions based on assessment findings. However, in both cases, the care plans were either not developed or not implemented as ordered, leading to residents experiencing pain and injury. Staff and leadership interviews confirmed the importance of care plans for communication and consistent intervention, and acknowledged that the deficiencies contributed to the residents' negative outcomes.