Failure to Develop and Implement Comprehensive Care Plan for Pain and Therapy Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical and rehabilitation needs. The resident, a cognitively intact male with a history of hypertension, spinal stenosis, low back pain, and recent left total knee arthroplasty, was readmitted to the facility following surgery. Despite orders for scheduled pain medications and physical therapy, the care plan did not include specific, measurable objectives or timeframes for pain management or physical therapy interventions. The care plan also lacked updates to reflect the resident's ongoing pain and therapy needs after his readmission and subsequent hospitalizations. Observations and interviews revealed that the resident expressed dissatisfaction with his pain management, stating that his requests for increased pain medication were not met and that he had not received physical therapy since returning from the hospital. Nursing staff confirmed the resident's concerns about pain management and were unsure if pain or therapy needs were addressed in the care plan. The Director of Therapy indicated that therapy services had been interrupted by insurance issues and repeated hospitalizations, but there was no evidence that these changes were reflected in the care plan. The facility's policy requires the interdisciplinary team to develop a baseline and comprehensive care plan within specified timeframes, including measurable objectives and updates based on changes in the resident's condition. However, the care plan for this resident did not include a focus on pain management or physical therapy, nor did it document person-centered interventions for these needs. This omission was confirmed by the Administrator and Regional Nurse Consultant, who acknowledged that pain and therapy were not properly addressed in the care plan, despite the resident's ongoing needs and multiple interactions with pain management and therapy providers.