Failure to Develop Comprehensive Care Plans Resulting in Resident Harm
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address the specific care needs of two residents, resulting in harm to one resident. For one resident with diagnoses including anemia, renal failure, and osteoarthritis, physician orders and MDS assessments indicated a need for total assist of two persons via Hoyer lift for transfers and dependence on staff for bed mobility. However, the resident's care plan did not specify the required level of assistance for bed mobility or transfers. During care, the resident rolled out of bed while only one staff member was present, resulting in bilateral leg fractures and subsequent hospitalization. Staff interviews confirmed that the care plan lacked necessary details regarding bed mobility assistance at the time of the incident. Another resident with muscle weakness, ataxic gait, and obesity also had physician orders requiring total assist of two via Hoyer lift for transfers, but the clinical record did not include a care plan for transfer status or bed mobility. Staff interviews confirmed the absence of a care plan addressing these needs. The deficiency was confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged the failure to develop comprehensive care plans for both residents.