Failure to Develop Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for three of five residents reviewed, as required by policy. For one resident with coronary artery disease, hypertension, and acute osteomyelitis of the right foot, the care plan did not include interventions for the use of a wound vac, despite physician orders and direct observation confirming its use. Another resident with anemia, diabetes, and a right leg above-the-knee amputation had a trapeze bar above the bed for mobility, but the care plan did not address interventions related to the trapeze, even though staff confirmed its use for transfers. A third resident with high blood pressure, diabetes, and dementia had physician orders for a wander guard device due to poor safety awareness, but the care plan lacked interventions and goals for elopement risk management. Staff interviews, clinical record reviews, and direct observations confirmed these omissions. The Director of Nursing and other staff acknowledged that the care plans did not include the necessary individualized interventions and goals to address these residents' specific care needs.