Failure to Develop Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific needs. For one resident with quadriplegia, diabetes, and feeding difficulties, the care plan did not include a 24-hour positioning plan as ordered by the physician, nor did it address the resident's communication barriers, despite the resident being Spanish-speaking and requiring an interpreter. Documentation such as the nurse aide care card and the resident care plan lacked information about the positioning plan and the need for specialized communication services, even though occupational therapy notes and physician orders specified these requirements. Interviews confirmed that staff were unaware of these omissions in the care plan. For another resident with a history of malignant neoplasm, malnutrition, and dysphagia, the care plan did not reflect ongoing dental issues, despite dental and hygienist notes documenting tooth pain and the need for further evaluation. The resident's dental discomfort was known to nursing staff, and previous assessments had recommended referral for treatment, but the care plan was not updated to include these dental concerns. Review of facility policy indicated that care plans should be revised to reflect current status and new problems, but this was not done for the resident's dental issues.