Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for nine out of 26 sampled residents, as required by policy and professional standards. Specific deficiencies included the absence of care plans for residents receiving nebulization therapy, those with a diagnosis of epilepsy and prescribed anti-seizure medication, and residents requiring the use of a craniotomy helmet, including documentation of non-compliance with helmet use. Additionally, care plans were missing for residents experiencing wheezing or shortness of breath, those with active infections, and residents prescribed blood thinners such as Eliquis and Warfarin. Surveyors observed and confirmed through interviews and record reviews that these omissions occurred despite clear evidence in the residents' clinical records and physician orders indicating the need for such care plans. For example, residents with new or ongoing respiratory issues were receiving nebulizer treatments or inhaled medications without corresponding care plans. Similarly, residents with significant neurological or cardiovascular diagnoses, such as epilepsy or atrial fibrillation, were prescribed critical medications without individualized care plans addressing their conditions or the use of these medications. Further, the facility did not assess or document appropriate call bell system needs for a resident with significant physical limitations, resulting in the call light being inaccessible and not tailored to the resident's abilities. Staff interviews confirmed that care plans were not initiated or updated in a timely manner, and that the responsibility for care planning was not consistently fulfilled by the nursing staff, including the MDS nurse, ADON, and DON. Facility policies required comprehensive, person-centered care plans with measurable objectives and timeframes, but these were not developed or implemented for the affected residents.