Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents with specific medical needs. For one resident at risk for falls, observations revealed that only one fall mat was placed at the bedside while the care plan required bilateral floor mats whenever the resident was in bed. Staff interviews confirmed that both sides should have had mats in place, but this was not consistently implemented as observed on multiple occasions. Two residents with diabetes who frequently refused blood glucose monitoring (accu-checks) did not have care plan focuses addressing their refusals, despite repeated documentation of refusals and staff education attempts in the electronic medical record. Staff interviews acknowledged that these refusals should have been care planned, but the care plan coordinator was not always informed or did not review all relevant documentation to identify the need for care plan updates. Additionally, a resident receiving oxygen therapy via nasal cannula at 3 liters per minute did not have a care plan focus for oxygen therapy, even though there was a physician order for oxygen use. Staff interviews confirmed that the care plan should have included this intervention from admission, but it was omitted. The facility's policy requires comprehensive care plans to address all nursing, medical, and psychosocial needs, but these requirements were not met for the residents identified.