Failure to Develop and Update Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for several residents, as required by policy. For one resident with severe cognitive impairment, the care plan did not address her diagnoses of allergies and constipation, despite these being documented in her medical record. Another resident, who had a history of encephalopathy and pancreatic cyst, had his care plan listing an indwelling catheter even after it had been removed, and this was confirmed by both observation and staff interview. A third resident, with moderate cognitive impairment and a high risk for wandering, had a physician's order for a WanderGuard device following increased wandering behavior. However, the use of the WanderGuard was not reflected in the care plan, and the resident was observed wearing the device without understanding its purpose. Staff interviews confirmed that the care plan should have been updated to include this intervention but was overlooked due to staffing limitations. A fourth resident, admitted and readmitted with a nephrostomy tube, did not have the presence or care of the nephrostomy tube included in her care plan, despite orders to monitor its output. Observation confirmed the presence of the nephrostomy tube, and staff acknowledged that it was not included in the care plan. Facility policy requires that all identified medical and nursing needs be addressed in the care plan, but this was not done for these residents.