Failure to Develop Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents with specific medical needs. For one resident with diagnoses including asthma and morbid obesity, the electronic medical record and physician orders indicated the use of oxygen therapy and anticoagulant medication, but there was no corresponding care plan addressing these interventions. Observations confirmed the resident was receiving oxygen, and the MDS Coordinator acknowledged the absence of care plan areas for both oxygen and anticoagulant use, despite documentation and physician orders supporting their necessity. Similarly, another resident with dementia, diabetes, COPD, and muscle weakness was receiving oxygen therapy and psychotropic medications, and required assistance with ADLs, but had no care plan addressing these needs. Multiple observations confirmed the use of oxygen and staff assistance with ADLs. The MDS Coordinator and Administrator both confirmed the lack of care plans for these areas. Additionally, a resident with PTSD had no care plan addressing this diagnosis, despite MDS documentation and staff interviews confirming the need. The failure to create care plans for these residents' specific needs was confirmed through record review, staff interviews, and direct observation.