Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for multiple residents, resulting in deficiencies related to individualized resident needs. For one resident with hemiplegia, aphasia, and diabetes, the care plan did not address the resident's report of misappropriation of funds. Although the resident reported $2,000 missing and an investigation was conducted, the care plan was not updated to reflect the allegation, the offer of a lock box, or any new interventions related to the incident. The Director of Nursing Services acknowledged that the care plan should have been updated to include these elements. Another resident with a history of respiratory failure, deep vein thrombosis, pulmonary emboli, and congestive heart failure had a care plan that failed to include problems, interventions, goals, or monitoring parameters related to congestive heart failure or respiratory distress. Despite documentation of these conditions in the resident's medical history and a recent hospitalization for related issues, the care plan did not reflect these significant diagnoses or the necessary care approaches. A third resident with anxiety, right-sided hemiplegia, and hemiparesis was not identified as a smoker in the care plan, nor were there interventions related to smoking such as supervision, staff assistance, or safety measures. The resident was observed smoking in the designated area, and the Director of Nursing Services confirmed that the care plan was incomplete and did not reflect the resident's current smoking status or staff practices. The facility's policy required comprehensive and individualized care plans, but these were not consistently developed or implemented for the residents reviewed.