Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents. One resident, admitted with lack of coordination, hemiplegia, and a need for personal assistance, was identified as being at very high risk for pressure ulcer development, with a Norton score of 7. Despite physician orders and a care plan intervention to apply protective heel booties while in bed, multiple observations showed the resident lying in bed without the booties, which were instead found on the wheelchair. The resident reported typically wearing the booties but stated that no one had assisted with putting them on that day. Interviews with nursing staff and the DON confirmed that care plans and orders should be followed as written, and that the resident should have the booties on at all times when in bed. Another resident, admitted with diagnoses including diabetes, adult failure to thrive, pain, and acute embolism and thrombosis of the deep veins, was found to have no care plan addressing Activities of Daily Living (ADLs) despite requiring substantial to maximal assistance for ADLs and transfers. Review of the resident's care plan and physician orders revealed no documentation regarding the level of assistance needed for ADLs, transfers, or eating. Staff interviews confirmed that the CNA Kardex, which should reflect the care plan, did not indicate the required level of assistance, and that an ADL care plan should be in place for all residents to guide staff in providing appropriate care.