Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, each with specific clinical needs that required individualized interventions. For one resident prescribed valproic acid for schizoaffective disorder and behavioral outbursts, the care plan did not address the use of this medication, omitting guidance for staff on monitoring, assessment, and management of potential side effects. Interviews with the MDS nurse and DON confirmed that the absence of a care plan for this medication could leave staff uninformed about necessary care and monitoring. Another resident was observed wearing an external heart defibrillator vest, but there was no care plan outlining interventions for the care, monitoring, or maintenance of the device. The RN and DON both acknowledged the importance of having a care plan to ensure staff understood the device's operation and maintenance requirements. The lack of such a plan meant that staff did not have clear instructions for managing the resident's cardiac device. Additional deficiencies included the absence of a care plan for a resident who refused restorative nurse aid services despite being dependent for mobility and ADLs, with no interventions documented to address the refusals or prevent functional decline. One resident with no natural teeth did not have a care plan addressing their edentulous status or oral care needs, and another resident receiving chlorpromazine via G-tube for hiccups had no care plan to monitor for side effects or guide care. In each case, staff interviews confirmed that the lack of individualized care plans resulted in insufficient communication and guidance for providing appropriate care.