Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents with specific medical needs, as identified through observation, interviews, and record reviews. For one resident with anxiety disorder and insomnia, there was no care plan initiated or implemented for the use of Buspirone, despite physician orders and staff acknowledgment that such a plan was necessary to ensure proper and effective interventions. The facility's own policy required a comprehensive, person-centered care plan to be developed within seven days of the Minimum Data Set (MDS) assessment, but this was not done. Another resident with diagnoses including enterocolitis due to Clostridium difficile and irritable bowel syndrome experienced severe abdominal pain, but no care plan was developed to address this symptom. The resident repeatedly reported pain, and pain medication was administered, but documentation did not consistently indicate the location of the pain. The care plan for pain did not address abdominal pain specifically, nor did the care plan for Clostridium difficile include monitoring for abdominal symptoms, contrary to CDC recommendations. A third resident with a history of recurrent urinary tract infections (UTIs) and multiple hospitalizations for UTIs did not have a comprehensive care plan addressing this issue. The only care plan found was a short-term plan following hospitalizations, which did not include interventions to prevent further UTIs. Additionally, a fourth resident receiving Hydrocodone-Acetaminophen for pain management did not have a care plan in place to address the use of this opioid medication, despite its black box warning and the need for monitoring for adverse effects. In each case, staff interviews confirmed the absence of appropriate care plans and acknowledged the importance of such plans for guiding care and monitoring resident conditions.