Failure to Develop and Implement Comprehensive Care Plans for Residents with Hospice and Parkinson's Disease
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents with significant medical needs. One resident, who was diagnosed with encephalopathy, respiratory failure, kidney disease, and cerebrovascular disease, was admitted to hospice care as indicated by physician orders and the MDS assessment. However, the resident's care plan did not include hospice care, despite documentation and staff acknowledgment of the resident's declining condition and active hospice involvement. Two other residents, both diagnosed with Parkinson's disease and prescribed carbidopa-levodopa, also lacked care plans addressing their primary medical condition. Their diagnoses and medication orders were documented in their records and MDS assessments, but their comprehensive care plans did not reflect interventions or goals related to Parkinson's disease. Staff interviews confirmed that these omissions were oversights and that care plans for these conditions were not created as required. Facility staff, including the MDS nurse, ADON, and DON, acknowledged during interviews that care plans are essential for ensuring all staff are aware of and provide appropriate care for residents' needs. The absence of care plans for hospice and Parkinson's disease was recognized as a failure to document and coordinate necessary care and services, as required by facility policy and regulatory standards.