Failure to Develop Comprehensive Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents. One resident was admitted with a diagnosis of Enterococcus bacteremia and was receiving intravenous antibiotics via a PICC line. Despite being cognitively intact and at risk for complications and infections related to the PICC line, there was no comprehensive care plan completed for this resident. Interviews with nursing staff confirmed that a care plan should have been in place, particularly addressing the PICC line and associated risks. Another resident, admitted with a left ankle fracture and diagnoses including anxiety and schizophrenia, was experiencing almost constant pain and was receiving both scheduled and PRN opioid pain medications. The care plan for this resident did not include specific focus areas, goals, or non-pharmacological interventions related to pain management or opioid use, nor did it address monitoring for adverse effects of these medications. Staff interviews confirmed the absence of these critical care plan components, despite the resident's ongoing pain and frequent administration of opioid medications.