Failure to Develop and Implement Comprehensive Care Plans for ADL and Catheter Care
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for five residents, specifically regarding Activities of Daily Living (ADL) and urinary catheter care. For one resident with diabetes who required total assistance with personal hygiene, observations revealed long fingernails with brown matter underneath, despite a care plan intervention for diabetic nail care by a licensed nurse. The resident reported repeatedly requesting nail trimming, and both CNAs and LPNs acknowledged that the nails were too long and should be trimmed by nursing staff, as indicated in the care plan. However, the intervention was not carried out as documented. Another resident with a urinary catheter had a physician's order and care plan intervention to check and empty the catheter drainage bag when it was half full. Despite this, the resident reported that the bag was not emptied as required, leading to overflow and a urinary tract infection. Observations confirmed that the drainage bag was more than half full, and staff acknowledged that the care plan was not followed. Additionally, a resident requiring extensive assistance with personal hygiene was observed multiple times with dark brown matter under their fingernails, and staff confirmed that nail cleaning was part of personal hygiene but had not been performed as needed. Further deficiencies included a resident who required moderate assistance with personal hygiene and was repeatedly observed with yellowish crusty matter on their eyelids. The resident reported that staff did not clean their eyes, and staff interviews confirmed that this care should have been provided according to the care plan. Lastly, a resident with a urinary catheter had no care plan addressing catheter use, despite physician orders for monitoring output. Staff were unaware of the catheter and acknowledged that a care plan should have been in place. These findings demonstrate a pattern of failure to develop and/or implement care plans as required by facility policy and regulatory standards.