Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for multiple residents, as required by policy and regulation. For one resident with dementia, major depressive disorder, and atrial fibrillation, the care plan for fall risk did not include the use of floor mats, despite their presence in the resident's room, and there was no documented provider order for their use. Additionally, the resident was observed in bed late in the morning, not yet cleaned up or gotten up for the day, with the call bell on the floor and floor mats in place, contrary to the care plan's directive to keep the call bell within reach and the environment safe and clutter-free. Another resident with malignant neoplasm of the kidney, type 2 diabetes, and heart failure had a care plan for edema that lacked documented goals or interventions. A third resident with inflammatory spondylopathies, chronic pain syndrome, cellulitis, and a venous or arterial ulcer had ongoing wound care orders and was being followed on wound rounds, but there was no comprehensive care plan addressing wounds, open areas, or impaired skin integrity. Interviews with facility leadership confirmed that care plans should include goals and person-centered interventions for each area of care, and that a care plan should have been in place for the resident's wound.