Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing all identified needs for three residents. For one resident with difficulty walking, weakness, and osteoporosis, a physician's order was in place for wound care of a left buttock pressure ulcer, but the care plan did not include any focus, interventions, or goals related to this wound. This omission was confirmed by a licensed nurse during an interview. Another resident with quadriplegia, multiple pressure ulcers, and an indwelling urinary catheter did not have a baseline care plan for Enhanced Barrier Precautions related to their wounds and catheter care, despite these being present and documented in the clinical record. A third resident, admitted with hemiplegia, respiratory failure, malnutrition, and requiring continuous oxygen, a urinary catheter, and a feeding tube, was noted in nursing documentation to be on 1:1 supervision for safety due to behaviors such as pulling on medical tubing. However, there was no care plan in place for this supervision, and the DON confirmed that no physician order or care plan existed for the required supervision. These findings were based on review of clinical records, observations, and staff interviews, and were not in accordance with facility policy and state regulations regarding resident care plans and nursing services.