Failure to Develop and Implement Comprehensive Care Plan for Sickle Cell Disease
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a primary diagnosis of sickle cell pain crisis. Despite the resident's complex medical history, including sickle cell/HB-C disease with crisis, alcoholic cirrhosis, aseptic necrosis of bone, multiple fractures, anemia, and end stage renal disease, the baseline care plan did not include any focus, interventions, or goals related to sickle cell disease or its management. The resident's medical records indicated a history of low hemoglobin levels and multiple blood transfusions, yet there was no evidence of ongoing assessment or care planning for these issues. Interviews with facility staff revealed a lack of awareness and training regarding the specific needs and symptoms associated with sickle cell disease. Nursing staff were not aware of any orders for regular monitoring of the resident's hemoglobin levels, and there was confusion about the process for obtaining and reviewing lab results. The facility's Regional Compliance Nurse and ADON acknowledged the importance of monitoring lab values and care planning for serious conditions but confirmed that these steps were not taken for this resident. The deficiency was further highlighted when the resident experienced heart palpitations and was transported to the emergency room by family, where a critically low hemoglobin level was discovered, resulting in hospital admission. The facility's own policies required individualized care plans based on comprehensive assessments, but these were not followed, placing the resident at risk for not receiving proper care and services due to inaccurate or incomplete care planning.