Failure to Develop and Implement Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with identified needs. One resident, who was admitted following a trimalleolar fracture of the right ankle and subsequent surgical repair, was observed multiple times with persistent right leg edema and skin discoloration. Despite these ongoing symptoms and documentation in the medical record regarding the need to elevate the extremity to address edema, there was no care plan initiated to address the edema. Both the QA nurse and LVN confirmed the absence of a care plan for this issue, acknowledging that it should have been developed by the licensed staff who observed and assessed the edema. Another resident, admitted with a diagnosis of depression and receiving Effexor XR for this condition, also did not have a care plan developed for the use of this psychotropic medication. The resident's medical record included provider orders for Effexor XR and instructions to monitor for side effects, but there was no care plan outlining how staff should monitor for side effects or evaluate the effectiveness of the medication. The QA nurse and DON both confirmed the lack of a care plan for depression and the use of Effexor XR, stating that such a plan was necessary to guide nursing staff in providing appropriate care. The facility's policy requires the development and implementation of a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes to meet identified needs. In both cases, the failure to initiate and develop care plans for the residents' specific conditions and treatments resulted in deficiencies in meeting the facility's own standards and regulatory requirements.