Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by its own policies and federal regulations. For one resident with diabetes using a Dexcom continuous glucose monitoring sensor, the care plan did not include specific interventions for monitoring the sensor site or ensuring site rotation, and there was no documentation by licensed nurses regarding the location or assessment of the sensor. Interviews with staff confirmed the lack of documentation and care plan interventions related to the sensor's use and site monitoring, despite physician orders and manufacturer guidelines requiring such oversight. Another resident receiving oxycodone for pain management did not have a care plan addressing their pain or the use of narcotic pain medication, even though the resident regularly reported pain and was administered the medication as needed. Staff interviews and medical record reviews confirmed the absence of a care plan problem for pain management, despite ongoing administration of pain medication and the resident's complaints of pain. Additional deficiencies included the lack of a care plan for a resident with moisture-associated skin damage (MASD) to the abdominal fold, despite a physician's order for daily topical treatment. There was also no care plan addressing a resident's behavioral safety risk after a pair of scissors was found at the bedside, nor was there a care plan for another resident's change in condition involving popped boils on the forearm. In each case, staff interviews and record reviews confirmed the absence of appropriate care plan development and documentation, contrary to facility policy and best practices.