Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for four residents, as identified through observation, interview, and record review. For one resident prescribed quetiapine for Lewy Body Dementia, the care plan required an Abnormal Involuntary Movement Scale (AIMS) assessment to monitor for tardive dyskinesia, but no such assessment was completed upon admission or after starting the medication. Both the Resident Care Manager and the Director of Nursing confirmed that the assessment was missing despite being required by the care plan. Another resident was prescribed a diuretic and an anticoagulant, with both medications documented in the Medication Administration Record and Minimum Data Set. However, the comprehensive care plan did not include interventions or monitoring for these medications. Staff interviews confirmed that care plans for these medications should have been in place but were not developed. A third resident with diabetes and a physician's order for routine insulin injections did not have a care plan addressing diabetes management or insulin administration until after the deficiency was identified. Additionally, a resident with contractures and an order for a right elbow extension and hand orthotic was not observed wearing the splint as required by the care plan on multiple occasions. Staff interviews and record reviews confirmed that the care plan was not being followed, and staff responsible for applying the splint had not ensured its use as directed.