Failure to Develop and Implement Individualized, Measurable Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, individualized care plans were developed and implemented for several residents, as required by both federal and state regulations. Specifically, care plans lacked person-centered goals, measurable objectives, and appropriate interventions for conditions such as respiratory infections, diabetes, nutrition, urinary tract infections, fluid restrictions, and resident choices. For example, one resident with a complex medical history including pneumonia, heart failure, and chronic kidney disease experienced multiple medication changes and ongoing respiratory symptoms, yet the care plan only addressed antibiotic use and oxygen therapy, omitting other relevant interventions for respiratory status and chronic cough. Another resident with diabetes, bilateral lower extremity amputations, and significant weight gain had a care plan that did not address nutritional choices, diabetic education, or set measurable weight goals, despite the resident keeping high-sugar snacks at the bedside and expressing knowledge of the risks. Similarly, a resident with a history of recurrent urinary tract and yeast infections had a care plan that only addressed a single episode of UTI and did not reflect the resident's infection history or all relevant interventions. Observations and interviews confirmed that care plans were not updated to reflect ongoing or recurrent issues, and that interventions were not tailored to the residents' individual needs and preferences. Additionally, a resident with chronic kidney disease and a physician-ordered fluid restriction was known by staff and family to be noncompliant with the restriction, but this was not reflected in the care plan. Interviews with staff, including the MDS Coordinator and DON, confirmed that care plans were often not personalized, and that acute issues were removed from care plans once resolved, without maintaining a history of significant conditions. The facility's own policy required individualized, comprehensive care plans, but in practice, care plans were not consistently updated or detailed to guide staff in providing individualized care.