Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, resulting in deficiencies related to unmet care needs. For one resident, clinical records showed multiple falls from her wheelchair, with documented interventions after each incident instructing staff to encourage her to lie in bed when appearing sleepy. However, these interventions were not incorporated into her official care plan. Additionally, despite the resident's use of an anticoagulant and the presence of a cardiac pacemaker, her care plan did not address these significant medical factors. Another resident was admitted with a urinary tract infection caused by MRSA, requiring antibiotics and contact isolation precautions. Documentation confirmed the presence of MRSA in her urine and the implementation of contact precautions, including signage and the use of personal protective equipment by staff. Despite these measures being in place, the resident's care plan did not include her history of urinary tract infections with a multi-drug-resistant organism or the need for contact isolation. Interviews with facility leadership and staff confirmed the absence of these critical interventions and medical conditions in the residents' care plans. The lack of comprehensive and updated care plans for both residents was identified through clinical record review, observation, and staff and resident interviews.