Failure to Develop Comprehensive Care Plans for Residents with New Conditions and Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to individualized care. For one resident with a history of abdominal pain, GERD, and Type 2 Diabetes Mellitus, the facility did not create a care plan to address new onset abdominal pain, despite documentation of moderate pain and a physician's order for hospital transfer. The resident had moderate cognitive impairment and required significant assistance with daily activities. Staff interviews confirmed that a care plan should have been implemented following the change in condition, but none was created, and the facility's policy requiring care plan updates after changes in condition was not followed. Another resident, admitted with diagnoses including Type 2 Diabetes Mellitus, diabetic neuropathy, depression, and bipolar disorder, was prescribed Depakote for poor impulse control and verbal aggression. Physician orders required monitoring for medication side effects and target behaviors. However, no care plan was initiated to address the use of Depakote, its intended purpose, or the monitoring of its effectiveness and side effects. Staff interviews confirmed the absence of a care plan for this medication, despite facility policy mandating comprehensive care plans for each resident that include measurable objectives and timeframes for meeting medical, nursing, mental, and psychosocial needs. The facility's failure to develop and update care plans in response to changes in condition and new medication orders resulted in incomplete documentation and a lack of individualized interventions for the residents involved. Staff and leadership acknowledged these omissions and confirmed that facility policies and procedures were not followed in these instances.