Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by its own policy. For one resident with severe dementia, depression, and anxiety, the care plan did not address the use of multiple psychotropic and opioid medications, despite medical records showing active orders for antipsychotic, antidepressant, antianxiety, anticonvulsant, and opioid drugs. The resident's care plan lacked documentation on monitoring for side effects or interventions related to these medications, even though specific monitoring instructions were present in the physician's orders. The MDS Coordinator confirmed that the care plan should have included these elements. For another resident with hemiplegia, contractures, and joint derangement, the care plan did not include interventions for passive range of motion (PROM) or the application of hand splints, despite physician orders specifying their use for contracture management. The resident's medical record indicated limited range of motion and the need for both left and right hand splints, but these interventions were not reflected in the care plan. The MDS Coordinator acknowledged that the care plan should have addressed the current use of hand splints and PROM.