Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for five out of twelve residents reviewed. Facility policy requires an interdisciplinary care plan for every resident, updated as needed and in accordance with state and federal requirements. However, documentation revealed that for several residents, care plans did not include goals and interventions for all active diagnoses or care needs. For example, one resident with a diagnosis of dementia did not have dementia care addressed in their care plan, despite the diagnosis being present for several months. Another resident with bipolar disorder and PTSD did not have these conditions included in their care plan, even though they were documented in psychiatric evaluations and the facility's diagnosis list. Additional deficiencies were noted for residents with complex medical and psychosocial needs. One resident with a history of depression and documented behavioral incidents, including verbal aggression and self-harm threats, did not have a care plan addressing depression, despite being prescribed medication for this condition. Another resident with a diagnosis of depression, cancer of the colon, and COPD did not have care plans for hospice care or oxygen therapy, even though orders for these services were present in the clinical record. Observations also indicated that a resident who valued group activities was repeatedly found alone in their room, suggesting a lack of individualized activity planning in accordance with their preferences. Interviews with facility leadership confirmed the failure to develop and implement comprehensive care plans for the identified residents. The deficiencies were cited under state regulations for resident care policies and nursing services, as the care plans did not reflect all current diagnoses, treatments, and resident preferences as required.