Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents as required. For one resident with diagnoses including anxiety disorder, depression, and unspecified dementia, the care plan did not include any focus, goal, or intervention related to anxiety management, despite an active physician order for Buspirone to treat anxiety. The MDS Coordinator acknowledged that the anxiety focus had been marked as resolved months earlier and recognized the omission, noting that daily order reviews occur but the care plan update was overdue. For another resident with multiple diagnoses including convulsions, osteoporosis, spastic hemiplegia, contractures, traumatic brain injury, and epilepsy, the care plan identified a risk for falls and specified the use of floor mats at the bedside as an intervention. However, during multiple observations, the floor mats were not in place as required, instead being found propped against furniture. Staff interviews confirmed that the mats should have been in place and that staff are expected to review and follow the care plan each shift, but the intervention was not implemented as documented.