Failure to Implement and Maintain Resident Care Plans for Advanced Directives and UTI History
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents, resulting in deficiencies related to care plan implementation. One resident with diagnoses including sleep apnea, heart failure, hypertension, and high cholesterol had a physician's order and personal preference for cardiopulmonary resuscitation (CPR), but there was no care plan in place reflecting this advanced directive. The Director of Nursing confirmed the absence of the care plan during an interview. Another resident with a history of type 2 diabetes and pneumonia experienced multiple episodes of pain, burning with urination, and abdominal discomfort, which were documented in progress notes. Despite a positive urine dip test and subsequent hospital diagnosis of cystitis and pyelonephritis, the resident's record did not contain a current care plan addressing UTIs or a history of UTIs. A discontinued care plan was provided, but there was no documentation of an active care plan at the time of the events.