Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, implement, and update comprehensive person-centered care plans for three out of four residents reviewed. For one resident with diagnoses including alcohol use, liver disease, psychoactive substance abuse, and PTSD, the care plan did not address these conditions despite the resident having intact cognition and documented incidents such as returning to the facility intoxicated and unable to stand. The care plan also did not reflect ongoing medical orders and interventions related to these diagnoses. Another resident, admitted with major depressive disorder, anxiety, kidney failure, and cholangitis, had a severely impaired cognitive status. The care plan for this resident did not address any of these significant medical and psychiatric conditions, even though there were active medication orders for their management. Similarly, a third resident with a recent urinary tract infection, left femur fracture, and artificial hip joint had a care plan that failed to address these diagnoses or the need for assistance with activities of daily living, despite therapy and pain management orders being in place. Interviews with facility staff, including the ADON, DON, CNAs, and the Administrator, revealed that care plans are relied upon for guiding resident care and should be updated promptly with any changes in condition or incidents. Staff acknowledged that the care plans were incomplete and not updated as required, particularly after significant events such as intoxication or changes in medical status. The facility's own policy emphasized the need for individualized care plans tailored to each resident's needs, which was not followed in these cases.