Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six residents, each with specific medical and psychosocial needs. For two residents requiring dialysis, care plans did not adequately address transportation arrangements, resulting in multiple missed dialysis treatments. One resident missed seven out of twelve scheduled dialysis sessions, leading to hospitalizations for severe hyperkalemia and volume overload. Another resident missed two consecutive dialysis treatments due to transportation issues, which also resulted in hospitalization. The care plans for these residents lacked sufficient detail and follow-up regarding dialysis transportation, and there was no consistent process to ensure alternative arrangements when transportation failed. A resident with a diagnosis of PTSD did not have an active or comprehensive care plan addressing this condition. Interviews with the MDS Coordinator, DON, and ADON confirmed the absence of a care plan for PTSD, acknowledging that the resident was at risk of not receiving appropriate care and interventions for their mental health needs. Additionally, a resident with significant ADL deficits, including limited mobility and a history of stroke, was observed to have long, untrimmed fingernails despite repeated requests for assistance. The care plan included interventions for personal hygiene, but staff interviews revealed confusion about responsibilities for nail care, resulting in the resident's needs not being met over several days. Another resident with chronic pain and wound care needs experienced gaps in pain management due to missing or delayed pain medication. Medication administration records showed missing signatures and documentation of out-of-stock medications, with staff interviews confirming that residents sometimes ran out of medication and that reordering processes were inconsistent. Finally, a resident with severe mobility impairment and a tracheostomy did not have a care plan focus or interventions for frequent repositioning to preserve skin integrity. The family expressed concerns about prolonged periods in soiled linens and lack of movement, and the DON confirmed that no task or documentation existed to prompt staff for regular repositioning.