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. In one instance, a resident who experienced a fall in the bathroom did not have a care plan addressing the actual fall event, despite documentation of the incident and the resident's ongoing knee pain. The care plan only addressed the risk for falls, not the specific event or its aftermath, until after surveyor intervention. Another resident admitted for short-term rehabilitation was receiving both a diuretic (Lasix) and an antipsychotic (Seroquel), but the care plan did not reflect the administration or monitoring of these medications. The resident had been receiving Seroquel at home and Lasix was newly ordered at the facility, yet no care plan was developed or implemented to address the use of these medications or their potential effects. Additional deficiencies were found for residents requiring oxygen therapy and anticoagulant medications, as well as for a resident with insulin-dependent diabetes and anticoagulant use. In both cases, the care plans did not include these significant medical needs, despite clear documentation in the medical records and medication administration records. Staff interviews confirmed that these omissions were not in line with facility policy and that the care plans were not updated to reflect the residents' current conditions and treatments.