Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for six residents, as identified through observation, interviews, medical record reviews, and policy review. For one resident with multiple complex diagnoses, including end stage renal disease requiring dialysis, diabetes, and pressure ulcers, the care plan lacked specific details such as the dialysis location, contact information, and schedule. Additionally, the care plan for pain and fall risk was generic and did not address the resident's specific risks or needs. The MDS nurse confirmed that the care plan was not tailored to the resident, attributing this to frequent hospitalizations. Another resident with chronic heart failure, COPD, and chronic kidney disease had a care plan that addressed incontinence and functional deficits without specifying the underlying causes or providing adequate interventions. The plan also failed to detail the reasons for fall risk and only included minimal interventions. The responsible MDS nurse acknowledged the care plan was incomplete, mistakenly believing another nurse had finished it. Similarly, a third resident with chronic heart failure and end stage renal disease did not have a care plan addressing pain or oxygen use, despite having an active order for pain medication. The MDS nurse confirmed the absence of a pain management plan. Additional deficiencies were found for residents with functional deficits and pressure ulcers. One resident's care plan did not specify the cause of functional deficits or include interventions for activities of daily living. Another resident with a history of incontinence had no care plan addressing bowel and bladder function, despite assessments indicating frequent or total incontinence. For a resident with multiple sclerosis and pressure injuries, the care plan inaccurately reflected the stage of pressure ulcers, listing them as stage II instead of unstageable, even as wound documentation showed deterioration. The facility's policy required care plans to be specific and individualized, which was not met in these cases.