Failure to Develop Individualized Care Plans for Incontinence and Oxygen Use
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents with specific clinical needs. For one resident with hemiplegia, hemiparesis, severe cognitive impairment, and frequent incontinence of bowel and urine, the care plan only included an intervention to administer medications as ordered and document their effectiveness. There were no additional interventions listed to address the resident's incontinence, such as assistance with toileting or changing soiled briefs. Both the MDS Coordinator and the Director of Nursing acknowledged during interviews that the care plan was insufficient and did not adequately address the resident's needs for incontinence care. For another resident with diagnoses including cough, dementia, and type 2 diabetes mellitus, and who had a physician order for oxygen administration via nasal cannula as needed to maintain oxygen saturation above 92%, the facility did not develop a comprehensive care plan to address oxygen use. The resident's Minimum Data Set indicated severe cognitive impairment and a need for substantial to maximal assistance with activities of daily living. Despite these needs and the physician's order, the care plans reviewed did not include interventions or monitoring related to oxygen therapy. The facility's policy required the development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes to meet each resident's identified needs. The lack of appropriate care planning for both residents was confirmed by staff interviews and record reviews, indicating that the facility did not follow its own policy and failed to ensure that care plans described the services necessary to maintain the residents' highest practicable well-being.