Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents with significant medical and cognitive needs, as required by facility policy and procedure. For one resident with a history of epilepsy, severe cognitive impairment, and a care plan intervention to apply sheep skin padding to side rails to prevent injury during seizures, observations revealed that the required padding was not in place. Both the assigned LVN and the DON confirmed that the care plan was not followed, and the intervention to confirm placement of the padding every shift was not implemented. Another resident, admitted with dementia, a maxillary fracture, and concussion, was prescribed medications for dementia and was assessed as moderately cognitively impaired and dependent for multiple activities of daily living. Despite these findings and documented behavior concerns related to dementia, there was no evidence of a comprehensive care plan addressing cognitive impairment or dementia care. The baseline care plan and progress notes lacked goals or interventions for dementia, and staff interviews confirmed the absence of a dementia care plan since admission. A third resident, with dementia, difficulty walking, and muscle wasting, was assessed as severely cognitively impaired and requiring supervision for mobility. Although informed consent for the use of bilateral half side rails was documented, there was no care plan initiated to address the use of these side rails. Both the reviewing RN and the DON acknowledged the lack of a care plan for side rail use, which is necessary to guide staff in meeting the resident's needs and monitoring the effectiveness of interventions. These deficiencies were identified through record reviews, staff interviews, and direct observations.