Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for multiple residents, as evidenced by record reviews and staff interviews. For one resident with a history of substance abuse and a diagnosis of osteomyelitis, there was no care plan addressing substance abuse, and staff confirmed that such a plan was not created. The resident's death certificate listed septic shock and necrotizing fasciitis as causes of death, with a history of IV drug and polysubstance abuse also noted. The Nursing Home Administrator acknowledged that a care plan for substance abuse should have been in place to identify potential for illicit substance use and guide interventions. Additionally, another resident who was dependent on staff for personal hygiene and toileting was care planned for two-person assistance, but records showed that care was routinely provided by only one person. This discrepancy was confirmed by the DON. A third resident, admitted with a tracheostomy, did not have tracheostomy care included in their care plan, and the DON confirmed this omission during a review of the care plan. These findings demonstrate a pattern of failure to ensure that care plans addressed all assessed needs and were implemented as written.