Failure to Implement and Update Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for several residents. For one resident with a cardiac pacemaker, the care plan did not include any mention of cardiac monitoring, despite documentation in hospital records and nursing notes indicating the presence and management of a pacemaker and related monitoring equipment. Another resident who used BiPAP therapy for respiratory issues and experienced increased nighttime anxiety did not have interventions listed for BiPAP/CPAP therapy in the care plan, nor was the presence of a nighttime sitter documented, even though the resident continued to employ a private caregiver overnight. Additionally, a resident with terminal lung cancer who used continuous oxygen and received nutritional supplements did not have physician orders for these interventions, and the care plan lacked focus, goals, or interventions for oxygen or supplement use. Observations confirmed the use of oxygen and the presence of nutritional supplements in the resident's room. Another resident who required assistance with activities of daily living (ADLs) and mobility, and who was observed propelling himself in a wheelchair, also did not have these needs addressed in the care plan. Staff interviews revealed reliance on separate paper documents rather than the official care plan for guidance on resident care needs. The facility also failed to implement care planned assessments for seatbelt use for a resident in a wheelchair. Although the care plan specified quarterly assessments to ensure the resident could unbuckle the seatbelt and that it was functioning for positioning, these assessments had not been completed since a change in the electronic health record system, due to the absence of a template. Staff interviews confirmed that physician orders for seatbelt use were obtained only once and that there was no specific facility policy for seatbelt use.