Failure to Implement Comprehensive Care Plan for Dependent Resident
Penalty
Summary
Facility staff failed to implement the comprehensive care plan for one resident with severe cognitive impairment and total dependence on staff for activities of daily living (ADLs). The care plan required staff to provide scheduled showers, incontinence care, and frequent monitoring of vital signs. Documentation revealed that showers were not provided on multiple scheduled dates across several months, with records marked as 'not applicable' or indicating the task was not completed. There was no evidence in the clinical record that the resident refused showers on those dates, and staff interviews confirmed that showers should have been provided and refusals documented if they occurred. In addition to missed showers, the resident's care plan required incontinence care and skin inspections with each episode and every shift. However, ADL documentation showed gaps where incontinence care was not recorded as provided on several shifts, with entries either left blank or marked 'not applicable.' Again, there was no documentation of refusals for incontinence care, and staff interviews confirmed the expectation that care and refusals should be documented in the electronic medical record. The care plan also included an intervention to monitor vital signs every two hours due to a history of poor intake, hypernatremia, and recent fever. Despite a physician's order for vital signs every two hours, the clinical record showed that vital signs were not documented at the required frequency, with only sporadic entries over the relevant period. Staff interviews confirmed that vital signs were to be monitored and documented as ordered. The facility's policy on care plan revisions did not provide guidance on implementing the care plan, and administrative staff were made aware of these concerns during the survey.