Failure to Develop Individualized Care Plans for Incontinence, Fluid Restriction, and Weight Loss
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans with measurable objectives, timeframes, and interventions for two of eighteen sampled residents. For one resident with severe cognitive impairment and total dependence on staff for activities of daily living, including toileting, there was no care plan addressing bowel and bladder incontinence, despite direct observation of staff providing incontinence care. Both the registered nurse and the director of nursing confirmed that a care plan for incontinence was missing and acknowledged its importance for ensuring continuity of care. Another resident, diagnosed with end stage renal disease and dependent on dialysis, experienced a significant weight loss of nearly 7% in one month and had a physician order for a strict fluid restriction. Despite these critical needs, there was no care plan in place to address the resident's fluid restriction or significant weight loss. The absence of these care plans was confirmed during interviews and record reviews with nursing staff and the director of nursing, who stated that care plans are essential for communicating interventions and ensuring staff follow prescribed care. Facility policies and procedures reviewed during the survey required the interdisciplinary team to ensure care plans documented renal conditions, necessary precautions, and individualized goals for managing significant weight changes. The policies also mandated that each resident have a comprehensive, person-centered care plan based on assessed needs, but these requirements were not met for the two residents identified.