Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required. For one resident admitted with a gastrostomy (feeding) tube and documented cognitive impairment, the Minimum Data Set (MDS) assessment indicated the need for a care plan addressing the feeding tube. However, a review of the medical record over an eleven-month period revealed that no such care plan was created. The MDS nurse was unaware of the omission, attributing responsibility to a previous nurse who was no longer employed, and the Director of Nursing confirmed that care plans should have been developed according to guidelines. For another resident with severe cognitive impairment, hemiplegia, and a history of falls, the care plan and physician orders required bilateral fall mats to be placed on both sides of the bed. After a fall, the care plan was updated to include this intervention. However, following a room transfer, only one fall mat was present, and the resident was unable to locate the second mat. Observations confirmed the absence of the required fall mat, and both the DON and Administrator acknowledged that the care plan was not being followed as written.