Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive care plans for several residents, as required. For one resident with a history of constipation and undergoing dialysis three times a week, neither condition was included in the care plan despite documented complaints of constipation and ongoing dialysis treatments. The omission was confirmed through interviews and record reviews, which showed that the care plan was only updated after the issue was identified by surveyors. Another resident reported ongoing constipation and chronic pain, with a medical history including Type II Diabetes, Major Depressive Disorder, and use of anticoagulant medication. Despite these significant health concerns and active medication orders for each, the care plan did not address constipation, anticoagulant use, depression, diabetes, or chronic pain. The DON acknowledged that these issues should have been included in the care plan, but review of the updated care plan showed that only constipation was added, leaving other conditions unaddressed. A third resident was observed with contractures of the left elbow and both hands, and medical records confirmed these diagnoses along with recommendations from occupational therapy for splinting and positioning. However, there was no evidence that a care plan had been formulated to address the contractures since admission, despite documentation of therapy recommendations and care plan meeting notes referencing therapy involvement. The DON confirmed the absence of a care plan for contractures and stated that therapy recommendations were expected to be discussed in meetings.