Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents, as required. For one resident admitted with multiple complex medical conditions, including end stage renal disease, dependence on dialysis, diabetes with neuropathy, atherosclerotic heart disease, hypertension, cirrhosis, heart failure, atrial fibrillation, osteoarthritis, and pneumonia, the care plan did not include documented goals or interventions for identified focus problems such as risk for falls, complications from anticoagulant use, activity involvement, ADL self-care, and potential complications related to dialysis, diabetes, and cardiovascular disease. Staff confirmed that the care plan remained incomplete since admission, despite the facility's policy allowing 14-21 days to complete care plans after admission assessment. A second resident's care plan was also found incomplete during record review. The care plan for this resident lacked specific instructions and measurable goals regarding activity participation and the resident's level of independence or dependence on staff for meeting emotional, intellectual, physical, and social needs. Staff acknowledged the incompleteness of the care plan and agreed that it required correction. These findings were based on interviews and record reviews conducted by surveyors.