Failure to Develop Individualized Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop individualized care plans for four residents, as evidenced by a review of clinical records and staff interviews. For one resident who was cognitively intact and frequently incontinent, there was no documented care plan addressing the long-term use of Methenamine Hippurate for chronic urinary tract infections, despite ongoing physician orders and nurse practitioner notes indicating the need for suppressive therapy. Another resident, who required assistance with daily care and had dementia, also received Methenamine for recurrent urinary tract infections without a corresponding care plan to address this antibiotic use. Additionally, a resident with cognitive intactness, a pressure ulcer, renal failure, and on dialysis had no care plans developed for the use of a bariatric air mattress or for dialysis treatments, even though these interventions were ordered and observed in use. A fourth resident, with moderate cognitive impairment, neurogenic bladder, and an indwelling urinary catheter, did not have a care plan addressing the care and treatment needs related to the catheter, despite observations confirming its use. These deficiencies were confirmed through interviews with the Director of Nursing and the Nursing Home Administrator.