Failure to Implement and Document Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and/or implement comprehensive care plans for three residents, resulting in unmet care needs and adverse outcomes. For one resident with a right below-knee amputation, the care plan and CNA Kardex specified a two-person assist for bed mobility. Despite this, only one staff member assisted the resident during incontinence care, leading to a fall from bed and a fracture of the distal right femur. Documentation and staff interviews confirmed that the care plan was in effect at the time of the incident and should have been followed. Another resident, assessed as severely cognitively impaired and fully dependent for ADLs, did not receive incontinence care and wound treatments as outlined in their care plan and physician orders. Multiple dates showed missing or inappropriate documentation for incontinence care, with staff confirming that such care should always be documented for a resident who is always incontinent. Additionally, wound care treatments were not administered or documented on several dates, and there was no evidence of resident refusal. The care plan also failed to address contracture management, despite the resident having a diagnosis and orders for splints and braces, as well as therapy recommendations for contracture prevention. A third resident with an indwelling urinary catheter had a care plan intervention to keep the catheter bag off the floor. However, observation revealed the catheter collection bag lying flat on the floor next to the bed. Staff interviews confirmed that the care plan should be implemented for resident safety. In all cases, the facility's own policies required timely development and implementation of individualized, measurable care plans, but these were not consistently followed or documented.