Failure to Develop and Implement Individualized, Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for multiple residents with specific medical needs and conditions. For example, one resident with epilepsy did not have a care plan addressing their diagnosis, despite being cognitively intact and having a documented history of epilepsy. The Director of Nursing confirmed that a care plan should have been in place but was not developed or implemented. Another resident with Alzheimer's disease, dementia, depression, and anxiety, who was receiving antipsychotic medication, had a care plan that lacked identification of resident-specific targeted behaviors, signs and symptoms, individualized interventions, non-pharmacological approaches, and measurable goals for antipsychotic use. The care plan only included general interventions such as medication administration and monitoring, without tailoring to the resident's specific needs. The Director of Nursing acknowledged that the care plan was incomplete in this regard. Additional deficiencies included the absence of care plans for residents receiving anticoagulant therapy, those with bladder management needs, and those admitted to hospice services. In several cases, care plans did not reflect new interventions after significant events, such as falls, or failed to document resident preferences and patterns. Staff interviews confirmed that these omissions were contrary to facility policy and expectations, and that care plans were not updated or individualized as required.