Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents with significant medical and psychosocial needs. For one resident with diagnoses including anxiety, depression, atrial fibrillation, and schizoaffective disorder, there was no care plan addressing vitamin D deficiency or the administration of oyster shell calcium, Trazodone, and Buspirone. The resident was severely cognitively impaired and dependent on staff for activities of daily living. Interviews with the MDS nurse and DON confirmed that care plans for these diagnoses and medications were missing, and that such plans are necessary to guide staff in providing appropriate care and monitoring for side effects. Another resident with diagnoses of depression, Alzheimer's disease, dementia, and diabetes mellitus was prescribed Trazodone for depression manifested by self-isolation. Despite severe cognitive impairment and dependence on staff for daily activities, there was no care plan addressing the resident's depression. The MDS nurse and DON both acknowledged the absence of a care plan for depression and emphasized that care plans are essential for communicating resident needs and ensuring quality care. A third resident with pulmonary embolism, COPD, dementia, and pleural effusion had a care plan instructing staff to provide oxygen as ordered and to educate about the risks of excessive oxygen for COPD. However, observations revealed that the resident was receiving continuous oxygen at a rate of 4.5 LPM, contrary to the physician's order of 2 LPM as needed. Staff interviews confirmed that the care plan was not followed, and the DON acknowledged that this deviation placed the resident at risk. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, which were not implemented in these cases.