Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for multiple residents, resulting in deficiencies related to medication management, use of medical devices, and environmental safety. For one resident prescribed PRN lorazepam for anxiety, there was no care plan addressing monitoring for side effects or behaviors associated with the medication, despite facility policy requiring such plans for psychotropic medications. Staff interviews confirmed that the absence of a care plan for monitoring could result in the resident not being properly observed for adverse effects or behavioral changes. Another resident using lower side rails per family request did not have a timely care plan developed to reflect this intervention. The care plan was created several days after the intervention was implemented, contrary to facility expectations that care plans be developed on the day of intervention. Observations and staff interviews revealed that the use of both upper and lower side rails was not always in accordance with orders, and the lack of a timely care plan could lead to staff not being aware of the correct interventions, potentially restricting the resident's movement or causing injury. Additional deficiencies included the failure to include the use of low air loss mattresses in the care plans of two residents at risk for pressure sores, despite physician orders and the presence of these devices in their rooms. Another resident prescribed Eliquis, an anticoagulant, did not have a care plan developed for its use after a medication change, leaving staff without guidance on monitoring for side effects. The facility also failed to implement a care plan intervention for a resident at risk of falls, resulting in a cluttered environment that impeded safe access to the restroom. Lastly, a resident with a history of elopement did not have an effective care plan in place, which resulted in the resident eloping from the facility. Staff interviews indicated a lack of awareness regarding the resident's elopement risk, and handoff communication did not consistently include this information.