Failure to Implement Individualized Care Plans for Two Residents
Penalty
Summary
The facility failed to implement individualized care plans for two residents, resulting in deficiencies related to the delivery of care and services. For one resident with diabetes mellitus and hypertension, the admission record and Minimum Data Set (MDS) indicated intact cognition and total dependence on staff for toileting, showering, and dressing. Despite a physician's order for quarterly lab draws, the resident reported that staff were unable to successfully draw her blood on three consecutive mornings. Interviews with nursing staff and the Director of Nursing (DON) confirmed that no care plan was developed to address the repeated unsuccessful lab draws or to guide staff in monitoring for potential infection related to these attempts. Another resident, with diagnoses including diabetes mellitus, hemiplegia following a stroke, anxiety disorder, and hyperlipidemia, required partial to moderate assistance with activities of daily living. The resident reported a concern regarding how a CNA turned and repositioned him, alleging inappropriate and abusive behavior during personal care. Review of the resident's Change in Condition (COC) evaluation and care plan revealed that the care plan did not address the alleged physical and sexual abuse. Nursing staff and the DON acknowledged that the care plan lacked specificity and did not include interventions or monitoring related to the abuse allegation. The facility's policy on comprehensive, person-centered care plans requires that care plans reflect current standards of practice and are revised as residents' conditions change. In both cases, the facility did not develop or update care plans to address the residents' specific needs and concerns, as confirmed by staff interviews and record reviews.