Failure to Include Self-Management in Resident Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were developed and implemented to address all resident needs, specifically regarding self-management of colostomy care and self-administration of medications. For one resident with a colostomy, the care plan included interventions for gastrointestinal status but did not address the resident's self-management of her colostomy, despite documentation and staff interviews confirming that the resident independently performed her own colostomy care and received supplies from staff. The omission was verified by the Regional Director of Clinical Services, who acknowledged that a care plan for self-management should have been in place. Additionally, another resident who was cognitively intact and legally blind had physician orders permitting unsupervised self-administration of several medications, including fish oil, calcium-vitamin D, and Systane Gel, with medications allowed at bedside. However, the care plan did not include self-administration of medications, and staff interviews confirmed this omission. The facility also lacked a self-administration of medication policy, as confirmed by the President of Clinical Services. These findings were based on record review, staff interviews, and policy review, and affected two of forty resident records reviewed.