Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans to address all identified needs for two residents. For one resident, who had diagnoses including anxiety disorder, major depressive disorder, and bipolar disorder, the care plan did not include an order for Risperidone, an antipsychotic medication that was being administered. The care plan listed other psychotropic medications but left the section for Risperidone blank, despite a physician's order for its use. The DON acknowledged that the omission was not noticed and stated that care plans are expected to be accurate to ensure all resident needs are addressed. For another resident with a history of cerebral infarction, hemiplegia, hemiparesis, and contracture of the right lower extremity, the care plan only addressed a contracture of the right elbow and did not include contractures of the right hip and knee. Observations confirmed the presence of contractures in the right hip and knee, and interviews with staff indicated that these were present upon admission but not reflected in the care plan. The MDS assessment for this resident was also found to be inaccurate regarding range of motion, which contributed to the incomplete care plan. Interviews with facility staff, including the former MDS nurse, DON, and Regional Director of Clinical Services, confirmed that the care plans were incomplete due to inaccurate assessments and documentation. The facility's policy requires individualized, comprehensive care plans based on thorough assessments, but this was not followed in these cases, resulting in the failure to address all medical, nursing, and psychosocial needs for the affected residents.