Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans to address the medical, mental, and psychosocial needs of three residents. One resident, with diagnoses including schizophrenia and moderate cognitive impairment, exhibited repeated behaviors of pushing on the exit door near her room, as documented in progress notes on multiple occasions. Despite these documented behaviors and staff awareness, there was no care plan in place to address her exit-seeking or wandering behavior until after surveyor intervention. Staff interviews confirmed that the behavior was not initially care-planned, and the resident was only redirected when she attempted to push on the door. Another resident, who had moderate cognitive impairment and required substantial assistance with activities of daily living, was prescribed both oxygen and anticoagulant therapy. However, there were no care plans with interventions to address the use of oxygen or anticoagulants, despite physician orders for both. Staff interviews, including those with the MDS coordinator and DON, confirmed the absence of these care plans and acknowledged that such omissions could result in resident needs not being addressed. A third resident, with advanced directives indicating Do Not Resuscitate (DNR) status, also lacked a care plan to address this directive. Although the resident's DNR status was documented in physician orders and on the DNR form, the care plan did not reflect this critical information. Staff interviews confirmed that the care plan should have included the DNR status to ensure the resident's wishes were respected. The facility's own policies require that care plans include measurable objectives and interventions for all identified needs, but these were not followed for the residents in question.