Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, resulting in deficiencies related to the management of diabetes, pressure ulcers, falls, and other care needs. For one resident with type 2 diabetes, diabetic neuropathy, an unstageable pressure ulcer, and a history of repeated falls, there was no documented care plan for diabetes management, pressure ulcer prevention/treatment, or fall prevention within the required timeframe after admission. Despite clear documentation of the resident's medical history and risk factors, care plans for these critical areas were delayed by several weeks. Communication breakdowns among providers and lack of clear protocols contributed to the absence of timely and appropriate care planning, as confirmed by interviews with the medical director, nurse practitioner, and nursing staff. Another resident admitted after a fall and hospitalization with a diagnosis of chronic insulin-dependent diabetes mellitus did not have a baseline care plan addressing diabetes management upon admission. The comprehensive care plan for diabetes was not developed until nearly two weeks after the resident's admission, despite the diagnosis being clearly documented in the hospital discharge information and MDS assessment. The DON confirmed the absence of a baseline care plan for diabetes for this resident. A third resident, admitted after a recent hospital stay, had multiple care needs identified in the MDS, including communication, behavioral symptoms, activities, dental care, and psychotropic drug use. Although the facility's MDS Care Area Assessment indicated that care plans would be developed for these areas, the resident's care plan did not address them. The DON confirmed that the care plans for these identified needs were not created as documented.