Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, as required by policy and regulation. For one resident with asthma who was observed receiving oxygen via nasal cannula, there was a physician's order and documentation in the medical record indicating the need for oxygen therapy, but no corresponding care plan addressing the use of oxygen was found. The Assistant Director of Nursing confirmed that oxygen use should have been included in the care plan, and the facility's policy requires measurable objectives and timeframes for all identified needs. Another resident with a state-level 2 PASARR determination for serious mental illness had documentation of depression and anxiety in the care plan, but the positive PASARR Level 2 status and associated specialized services were not identified or addressed in the care plan. Social workers acknowledged that this information was missing and should be included, and the Director of Nursing confirmed that the care plan should reflect PASARR Level 2 status and related services, as outlined in facility policy. Additional deficiencies were noted for residents requiring a hand orthotic and for a resident with frequent incontinence. In both cases, physician orders and assessment data indicated the need for specific interventions (hand roll and incontinence care), but these were not documented in the residents' care plans. Staff interviews confirmed that such needs should be included as focus areas in the care plans, in accordance with facility policy, but were omitted.