Failure to Develop Comprehensive Care Plans for Dialysis and Pain Management
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents with specific clinical needs. One resident with end stage renal disease and dependent on hemodialysis was admitted with orders for dialysis three times per week, but there was no evidence of a care plan addressing dialysis in the resident's records. The MDS Coordinator acknowledged that a dialysis care plan is typically completed but was unsure why it was missed in this case. The Executive Director confirmed the expectation that a dialysis care plan should have been in place for this resident. Another resident with a diagnosis of chronic pain, moderate cognitive impairment, and active orders for both scheduled and as-needed oxycodone with acetaminophen, also lacked a care plan addressing pain management. The MDS Coordinator could not locate a pain-related care plan for this resident and did not know how it was missed. Both the Executive Director and the Director of Nursing Services stated their expectations that care plans should be completed to address residents' needs, including pain management.