Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents. For one resident, there was no care plan in place to address the use of bed rails, despite the presence of a signed consent form for bed rail use and multiple observations of the resident with and without bed rails in place. The absence of a care plan for bed rail use was confirmed by the Interim Director of Nursing (IDON) during a phone interview. For another resident, the care plan did not address the resident's declining range of motion (ROM), even though assessments indicated impairments in both upper and lower extremities. The IDON confirmed that ROM exercises were not included in the care plan, and that ROM interventions were only added after the issue was identified. The lack of documentation and planning for ROM needs was acknowledged by facility staff during interviews and record reviews.