Failure to Address Diuretic Use and Smoking in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents, resulting in deficiencies related to medication management and behavioral interventions. For one resident with chronic obstructive pulmonary disease, the medical record showed an active physician order for Furosemide, a diuretic, but the resident's care plan did not address the use of this medication. This omission was confirmed by the Director of Nursing during an interview, verifying that the care plan lacked necessary information regarding the resident's diuretic therapy. In a separate case, another resident with diagnoses including nicotine dependence and psychoactive substance abuse was observed to be non-compliant with the facility's no-smoking policy, regularly smoking outside the building. Despite documentation in progress notes and staff awareness of the behavior, the resident's care plan did not address smoking or related interventions. Both the LPN and the Director of Nursing confirmed that the care plan had not been updated to reflect the resident's ongoing smoking behavior and non-compliance with facility policy.