Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in unmet care needs. One resident, admitted with chronic and abdominal pain, experienced face and neck swelling. Despite reporting the swelling and requesting interventions such as ice application, there was no care plan addressing this issue, and progress notes only documented the complaint and a general ongoing plan of care. The Director of Nursing confirmed the absence of a care plan for the swelling, acknowledging its importance for proper treatment. Another resident with multiple sclerosis, requiring two-person assistance for activities of daily living (ADLs), was turned in bed by a single CNA, contrary to the care plan's specified intervention. Both the resident and the CNA confirmed that care was provided by only one staff member. The Director of Staff Development verified this deviation from the care plan and emphasized the necessity of following prescribed interventions to ensure proper care. Facility policy also required staff to check care plans for specific positioning needs and the number of staff required.