Failure to Develop and Implement Complete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents, resulting in a deficiency. For one resident, the admission record showed diagnoses of chronic respiratory failure and hypotension, with the Minimum Data Set (MDS) indicating a need for two-person assistance for repositioning in bed. The MDS Nurse confirmed that this level of assistance was necessary for safety and should have been included in the care plan, but no such care plan was present. The absence of this care plan meant that staff did not have documented guidance on the required assistance level for safe care. For another resident, the admission record listed muscle wasting, lack of coordination, and generalized muscle weakness, with the MDS indicating substantial to maximal assistance needed for mobility. A progress note documented a verbal exchange between the resident and a responsible party, which was considered possible verbal abuse. The Licensed Vocational Nurse and the Director of Nursing both stated that incidents of suspected or alleged abuse should be care planned to prevent psychosocial harm and future incidents. However, no care plan was developed to address the suspected abuse, contrary to facility policy requiring care plan updates for such events.