Failure to Develop Comprehensive Care Plan for Resident with Wounds and Constipation
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered comprehensive care plan for one resident with multiple medical needs. The resident was admitted with diagnoses including type 2 diabetes and constipation. Despite having physician orders for several laxatives and wound treatments for the left foot, the comprehensive care plan did not include interventions for either constipation or the wounds. The omission was identified through record review, observation, and interviews with staff and the resident. Interviews with the MDS Coordinator, DON, and Administrator confirmed that the care plan should have been updated to reflect the resident's current clinical conditions, including the development of two wounds and ongoing constipation. The MDS Coordinator acknowledged that the lack of care plan initiation was an oversight, and both the DON and Administrator stated that care plans are expected to accurately reflect residents' needs and be updated with any changes in condition.