Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the current medical status and nursing services for multiple residents. For one resident with lower extremity edema and vascular wounds, there were physician orders for elastic stockings and diuretic therapy, but the care plan did not include interventions or monitoring related to edema, use of elastic stockings, or diuretic side effects. Staff interviews confirmed that these aspects were missing from the care plan and should have been included. Another resident with multiple sclerosis, epilepsy, and recent leg fractures expressed a desire to be discharged to an independent living facility. Although social services had assisted with the process and documented ongoing discharge planning in progress notes, there was no current or active discharge care plan in place. Staff interviews confirmed the absence of a discharge care plan despite the resident's ongoing interest and involvement in discharge planning. A third resident with dementia had a care plan that addressed cognitive impairment but did not include all known behaviors or individualized approaches used by staff, such as specific redirection techniques and personal preferences. Staff described various dementia-related behaviors and interventions used in practice, but these were not reflected in the written care plan. The Director of Nursing confirmed that care plans are expected to be updated with changes in condition and to communicate necessary care interventions.