Failure to Develop and Implement Individualized Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, implement, and individualize comprehensive care plans for three residents, resulting in deficiencies related to unmet physical, psychosocial, and functional needs. For one resident with a history of brain aneurysm, stroke, chronic kidney disease, and depression, there was no person-centered care plan addressing recent onset of auditory hallucinations, self-injurious behavior, or an alleged suicide attempt. Despite documented incidents of the resident pulling out dialysis lines and expressing suicidal ideation, the care plan was not updated to reflect these significant changes in condition. Additionally, the use of Sertraline and Lorazepam for this resident was not supported by a care plan that identified specific targeted behaviors, non-pharmacological interventions, or measurable treatment goals. Another resident with severe cognitive impairment, dementia, and unspecified psychosis was administered Risperidone and Mirtazapine daily. However, the care plan did not specify resident-specific symptoms or targeted behaviors for these medications, nor did it include individualized non-pharmacological interventions or measurable goals of treatment. The Assistant Director of Nursing confirmed that the care plans lacked these essential elements and that the medications were being administered without clear documentation of their intended outcomes or alternative approaches. A third resident with a chronic left lower extremity wound, a history of wet gangrene, multiple debridements, and skin grafts did not have a care plan addressing the management of their chronic wound. Despite ongoing wound care orders and regular observation of the wound, the comprehensive care plan failed to include interventions or goals related to wound management. Interviews with nursing staff confirmed the presence of the wound and the absence of a corresponding care plan.