Failure to Develop Comprehensive Care Plans for High-Risk Conditions
Penalty
Summary
The facility failed to develop individualized, person-centered comprehensive care plans for two residents with high-risk conditions. One resident, admitted with atrial fibrillation and coronary artery disease, was prescribed an anticoagulant medication and was severely cognitively impaired. Despite these factors, the resident's care plan did not include any indication of anticoagulant use. Interviews with the MDS nurse, admitting nurse, ADON, DON, and Administrator revealed that the admitting nurse did not add high-risk medications to care plans during admission and was unaware that this was required. The ADON, DON, and Administrator all stated that high-risk medications should be included in care plans upon admission, but were unaware that this had not occurred for this resident. Another resident, admitted with diabetes mellitus type II and also severely cognitively impaired, was receiving sliding scale insulin, oral hypoglycemic medication, blood glucose checks, and a consistent carbohydrate diet. However, the resident's comprehensive care plan did not address diabetes mellitus type II. Similar to the first case, the admitting nurse did not add the diagnosis to the care plan and was unaware that this was part of the admission process. The ADON, DON, and Administrator each indicated that high-risk diagnoses such as diabetes should be included in care plans upon admission, but were unaware that this had not been done for this resident.