Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies related to care planning. For one resident prescribed an anticoagulant (Apixaban) for acute embolism and thrombosis, there was no care plan addressing the risks associated with anticoagulant therapy, such as monitoring for bleeding. This omission was confirmed by both the MDS Coordinator and the DON, who acknowledged that a care plan should have been initiated when the medication order was entered. The resident was cognitively intact at the time of the deficiency. For another resident with Parkinson's Disease and dyskinesia, the facility failed to implement the care plan for Activities of Daily Living (ADLs), specifically regarding bathing and showering assistance. The resident, also cognitively intact, reported not having received a bath or shower since admission, and was observed to have a foul odor. The care plan indicated the need for partial/moderate assistance with bathing, but this intervention was not carried out as documented.