Failure to Develop Comprehensive Care Plans for High-Risk Medication and Sensory Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing all identified needs for two residents. For one resident with moderate cognitive impairment and diagnoses including cataracts, glaucoma, or macular degeneration, the MDS assessment triggered care areas for both visual function and communication. Despite documentation that these areas would be addressed, the care plan did not include interventions for vision or communication. Observations confirmed the resident's ongoing difficulty reading the activity calendar due to small print, and staff acknowledged the omission of these care areas from the care plan. For another resident with severe cognitive impairment and multiple diagnoses, including hypertension, dementia, Parkinson's disease, depression, insomnia, and agitation, the care plan did not address the use of a high-risk medication, Lorazepam, which had been administered multiple times over several months. The care plan lacked mention of the medication, non-pharmacological interventions, or potential side effects, despite facility policy and staff expectations that high-risk medications should be included in the care plan when implemented.