Failure to Implement and Develop Comprehensive Care Plans for Residents with Seizure Disorder and Pressure Wound
Penalty
Summary
The facility failed to implement and document appropriate care plan interventions for two residents with significant medical needs. For one resident with a history of paranoid schizophrenia, epilepsy, and major depressive disorder, the care plan specified the use of padded side rails as a seizure precaution to prevent injury. Despite this documented intervention, observations on multiple occasions revealed that the resident's bed did not have padded side rails. Staff interviews confirmed that the intervention was not in place, and both the CNA and LVN acknowledged that the care plan was not being followed, which was also confirmed by the Director of Nursing. For another resident with chronic obstructive pulmonary disease, diabetes mellitus type II, and hemiplegia, the facility failed to develop a care plan addressing a newly identified open wound on the sacrococcyx. The resident required substantial assistance with mobility and had orders for specific wound care treatments. However, review of the records and staff interviews revealed that no care plan had been written for the wound, despite recommendations from a wound consult and ongoing wound care orders. The LVN responsible for the resident's care admitted to not creating the care plan due to being in training with the DON. The facility's own policy and procedure on comprehensive care plans requires that qualified staff are notified of their responsibilities and that care plans are developed and implemented to address residents' medical, nursing, and psychosocial needs. In both cases, the lack of implementation and development of care plans resulted in the potential for residents not receiving appropriate interventions as identified in their assessments.