Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, as required, resulting in unmet needs related to skin conditions, use of assistive devices, and behavioral non-compliance. For one resident, multiple dried scabs and an open area on the left knee were observed, with a physician's order for wound care in place, but no corresponding care plan addressing either the skin condition or the use of an electric wheelchair, which had been removed due to safety concerns. The clinical record also lacked documentation of a care plan for the resident's wheelchair use, despite occupational therapy involvement and administrative acknowledgment of the omission. Another resident with vascular dementia and diabetes had an open area on the right heel, with a physician's order for wound care, but no care plan addressing the pressure ulcer. Similarly, a resident with severe cognitive impairment and a history of adjusting her bed to a high position was observed repeatedly with the bed elevated and the control within reach, yet there was no care plan addressing her non-compliance with keeping the bed in a low position, as confirmed by staff interviews and record review. Additional deficiencies included a resident with hemiplegia and severe cognitive impairment who was known to throw his call light out of reach, but lacked a care plan to address this behavior, and another resident with stage 2 and stage 3 pressure ulcers who was receiving wound care per physician orders, but whose clinical record did not contain a care plan for these skin conditions. In each case, the absence of individualized, measurable care plans was confirmed by administrative and nursing staff, and the facility's own policy requires such plans to be developed and updated as resident needs change.