Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans with measurable goals and interventions for multiple residents with complex medical needs. For one resident with interstitial pulmonary disease, diabetes, and a central IV line, there was no documented care plan addressing the management and care of the central IV line, despite physician orders specifying dressing changes and site monitoring. Observation revealed the dressing was not changed as scheduled, and staff acknowledged the absence of a care plan for this intervention. Another resident with a traumatic brain injury, quadriplegia, and a recent right foot fracture was provided with a foot immobilization boot following physician and therapy orders. However, the care plan did not include any focus, goals, or interventions related to the use of the immobilization boot, even though the resident was dependent for all ADLs and had a history of falls and recent surgery. Staff interviews confirmed that a care plan for the boot should have been implemented but was not. Additional deficiencies included the lack of a care plan for a resident's preference to use a Spanish-speaking interpreter during medical communication, despite documentation of this need in the MDS and direct resident statements. Another resident with an indwelling urinary catheter and recent UTI did not have a care plan addressing catheter care, even though physician orders and nursing notes documented ongoing catheter management. Finally, a resident with dysphagia and a mechanically altered diet did not have a care plan for dietary needs and feeding assistance, despite physician orders and observed feeding by staff. In each case, the absence of individualized, measurable care plans for these specific needs was confirmed through record review, staff interviews, and direct observation.