Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the care needs of twelve residents. For several residents, care plans did not address critical medical conditions or physician orders, such as malnutrition, use of ace/compression wraps, specific catheter types and justifications, daily or weekly weights with notification parameters, and NPO status. In multiple cases, the care plans omitted essential details about the residents' diagnoses, treatments, and monitoring requirements, despite these being documented in the residents' medical records and confirmed by staff interviews. Residents with complex medical histories, including severe cognitive impairment, heart failure, kidney disease, malnutrition, and those on hospice or palliative care, were affected by these omissions. For example, one resident with severe cognitive impairment and malnutrition did not have a nutrition care plan, and another with a suprapubic catheter did not have the catheter type or justification documented in the care plan. Additionally, care plans failed to address specific interventions such as daily weights for residents on diuretics, non-weight bearing status affecting bathing routines, and individualized smoking safety plans. Further deficiencies included the lack of person-centered care planning for mental health diagnoses, such as anxiety and PTSD, and the absence of non-pharmacological interventions for psychotropic medication use. Care plans for residents on hospice did not specify advanced directives, goals of care, or the hospice provider. Other omissions included not updating continence care plans to reflect current status, not care planning for bed placement against the wall, and not specifying respiratory care details such as oxygen saturation targets and delivery methods. These failures were confirmed through staff interviews and record reviews, indicating a systemic issue in care plan development and implementation.