Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the full scope of residents' medical, psychosocial, and mental health needs, as identified through record review, observation, and staff interviews. For one resident with diagnoses including malignant neoplasm of the prostate and COPD, who was receiving hospice services and using oxygen, there was no care plan in place for oxygen use, despite observations confirming its use and facility policy requiring such a plan. Another resident receiving high-risk anticoagulant medication did not have a care plan addressing the monitoring and management of side effects, even though physician orders specified monitoring requirements. A resident with a colostomy and suprapubic catheter, who was cognitively intact and self-managed his care, had care plans that did not reflect his self-management, instead listing only standard nursing interventions. For a resident with severe cognitive impairment and chronic wounds requiring enhanced barrier precautions (EBP), there was no care plan addressing EBP, despite physician orders and staff confirmation that such a plan was required. Additionally, a resident with PTSD and other mental health diagnoses had an incomplete care plan that did not identify specific triggers or interventions to alleviate symptoms, with only a single generic intervention documented and no measurable goals. These deficiencies were confirmed through interviews with nursing and social work staff, who acknowledged the absence or incompleteness of required care plans. Facility policies reviewed indicated that comprehensive, person-centered care plans with measurable objectives and time frames were required for all identified needs, but these were not consistently developed or implemented for the affected residents.