Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
Multiple deficiencies were identified in the facility's development and implementation of comprehensive care plans for several residents. For nail care, a resident who required substantial assistance with personal hygiene was observed to have long, discolored, and unclean fingernails and toenails. Despite the resident's requests for help and staff acknowledgment of responsibility for nail care or referral to a podiatrist, there was no care plan addressing nail care, no documentation of podiatrist visits, and no evidence that nail care was provided. In the area of toileting hygiene, a resident dependent on staff for toileting and incontinent care reported not receiving assistance during the night shift, despite care plans specifying assistance every 2-3 hours and the resident's request to be woken for changes. Documentation showed frequent missing entries for toileting hygiene, and staff interviews confirmed that care was expected but not consistently documented or provided, with no records of resident refusal. Additional deficiencies included the lack of a care plan for bed positioning for a resident with a leg fracture and severe cognitive impairment, whose bed was placed against the wall without assessment or documentation of risks and benefits. Another resident with gastroparesis did not receive the prescribed small, frequent meals, and a resident with a broken tooth was not referred to dental services as indicated in their care plan. Furthermore, a resident with pain-related diagnoses had no pain management care plan, and a cognitively intact resident did not receive or have documentation of participation in activities as outlined in their care plan. These failures to develop and implement care plans resulted in unmet care needs for multiple residents.