Failure to Implement Comprehensive Care Plans for Elopement Risk, Pain, and Antibiotic Therapy
Penalty
Summary
The facility failed to implement comprehensive care plans for three residents with specific clinical needs. One resident with diagnoses including paranoid schizophrenia, anxiety, and dementia was identified as cognitively impaired and at risk for elopement, with a history of wandering into unsafe areas. Although the resident wore a WanderGuard device as ordered by the physician, there was no documentation of an elopement care plan in the resident's record. The assessment section for initiating an elopement care plan was not completed, with a comment indicating the staff believed a care plan was already in place. Another resident with fibromyalgia, anemia, hypertension, stroke, and anxiety, who was cognitively moderately impaired, received both PRN pain medication and duloxetine for pain management. Despite ongoing pain management interventions and a physician's note to continue duloxetine, there was no care plan addressing the resident's pain. Additionally, a third resident with severe cognitive impairment, urinary retention, and fractures was receiving daily antibiotic therapy as ordered, but the record lacked a comprehensive care plan related to antibiotic use. In each case, the absence of appropriate care plans was confirmed by the DON during interviews.