Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement complete care plans to address the specific needs of several residents, as evidenced by medical record reviews and staff interviews. For one resident with dementia, major depressive disorder, and anxiety disorder, there was no care plan addressing the use of prescribed anxiety medication, despite a physician's order for Ativan. Another resident with Alzheimer's disease, Parkinson's disease, anxiety disorder, and diabetes mellitus did not have a care plan for urinary catheter care, even though there was a physician's order for catheter care every shift. Additionally, a resident with cellulitis, chronic kidney disease, diabetes mellitus, and multiple ulcers did not have a care plan for impaired skin integrity, despite documentation of eight venous and arterial ulcers. A further review revealed that a resident with COPD, congestive heart failure, hypertension, hemiplegia, hyperlipidemia, and protein-calorie malnutrition, who was accepted for hospice care, did not have hospice services included in their care plan. These deficiencies were confirmed through interviews with the MDS nurse and the Director of Nursing, who verified the absence of appropriate care plans for the identified needs of the residents.