Failure to Develop and Revise Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and revised as required for three residents. For one resident with a history of falls and a physician's order for bilateral floor mats, the care plan did not include this intervention, despite documented falls and the presence of the mats during observation. The Director of Nursing (DON) confirmed that the care plan lacked this intervention. Another resident experienced a significant, unplanned weight loss of 24 lbs (17.91%) over a period of less than three months. Although the resident's care plan noted a nutritional problem, it did not address the severe weight loss, and both the Registered Dietician and DON acknowledged the omission. A third resident, who was cognitively intact, sustained facial abrasions following a physical altercation. While the care plan identified the resident as a victim of assault, it did not include interventions for the facial injuries. The DON confirmed that there was no care plan or interventions for the injuries, and agreed that the injuries represented a change in condition. The Administrator and DON acknowledged these findings during the survey.