Failure to Develop and Implement Accurate, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents with specific clinical needs. For one resident with congestive heart failure, pneumonia, and a dependence on supplemental oxygen, the care plan did not include any interventions or care area addressing the resident's continuous oxygen therapy, despite physician orders and documentation showing ongoing use of oxygen since admission. This omission was confirmed by both the MDS Coordinator and the DON, who acknowledged that the resident's need for continuous oxygen was not reflected in the care plan due to oversight. For another resident with chronic respiratory failure, hypoxia, diabetes, and epilepsy, the care plan inaccurately included the use of bilateral hand mitts in addition to an abdominal binder for protection of a feeding tube. However, medical records, staff interviews, and the resident's MAR confirmed that only the abdominal binder was used, and there were no physician orders for hand mitts. The inclusion of hand mitts in the care plan was identified as a mistake by the MDS Coordinator, and staff confirmed that the resident never used them. The DON and Administrator both expected the care plan to accurately reflect the resident's current interventions.