Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans (CPs) for three residents with specific care needs. For one resident with pneumonia, asthma, and respiratory failure who required supplemental oxygen, there was no CP addressing respiratory conditions or oxygen use, despite observations of the resident using oxygen and staff confirming the absence of a relevant CP. Another resident with respiratory issues and kidney disease was observed with swollen feet, but no CP or physician's orders were in place to guide staff in monitoring or addressing the swelling, as confirmed by staff review. A third resident, who was blind in one eye and dependent on staff for daily care, was observed with multiple bruises on the arms, neck, and chest following a hospital readmission. There was no CP or physician's order directing staff to monitor or document changes in the bruises. Staff interviews confirmed the lack of care planning and monitoring instructions for these conditions, contrary to facility policy requiring comprehensive CPs to address all identified care needs.