Failure to Develop Comprehensive and Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for several residents, specifically those with indwelling catheters, depression, and anxiety. For multiple residents with catheters, including those with moderate cognitive impairment and recent hospitalizations for fractures, the care plans lacked any focus, goals, or interventions related to catheter use. Documentation and interviews confirmed that these omissions were present at the time of the survey, and the Director of Nursing acknowledged that care plans for catheter use had not been developed as expected. Additionally, residents with diagnoses of depression and anxiety who were prescribed antianxiety and antidepressant medications did not have individualized care plans that identified target behaviors or non-pharmacological interventions. The care plans contained general statements and interventions that were not specific to the individual residents' symptoms or needs. Physician orders for monitoring behaviors were also not tailored to the residents, and documentation did not describe specific signs or symptoms of anxiety or depression. The facility's own policy required that care plan goals and objectives be resident-oriented, behaviorally stated, measurable, and based on comprehensive assessments. However, the care plans reviewed did not meet these standards, as they failed to include individualized, measurable goals and interventions for the residents' identified conditions. Staff interviews further confirmed that the care plans were not personalized and did not provide clear guidance for addressing the residents' specific needs.