Failure to Implement Individualized Care Plans for Oral Care and Fall Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with individualized oral care interventions for a resident with a tracheostomy who was dependent on a ventilator. The resident was observed with very dry, cracked lips and a thick layer of dry crust, and was seen rubbing her lips with her hand. During interviews and record reviews, nursing staff confirmed that there was no care plan or intervention in place for oral care, despite the resident's dependence on staff for all activities of daily living and the facility's own policies requiring individualized care plans and oral hygiene support for residents unable to perform these tasks independently. Additionally, the facility failed to implement a care plan intervention for another resident who required a floor mat for injury prevention as ordered. The resident, who had diagnoses including respiratory failure, cancer of the larynx, and dysphagia, was found on the floor without a floor mat in place, despite an active order for one to be provided on the left side of the bed. Nursing staff confirmed that the floor mat was not present, and the care plan indicated the intervention should be in place if indicated. Both deficiencies were identified through direct observation, interviews with nursing staff, and review of facility policies and resident records. The facility's policies require ongoing assessment and revision of care plans to meet residents' medical, physical, and psychosocial needs, including specific protocols for oral care and fall prevention, which were not followed in these cases.