Failure to Develop Comprehensive Care Plans for Smoking, Mobility, and Anticoagulant Use
Penalty
Summary
The facility failed to develop comprehensive care plans addressing all identified needs for three of four sampled residents. For one resident with COPD who was alert and oriented, the care plan did not include a focus, goal, or interventions related to safe smoking practices, despite the resident being observed smoking independently off facility property. Facility policy required evaluation and care planning for residents who smoke, but the care plan was not updated to reflect this until after the observation. Staff confirmed that the omission was due to a computer system change that resulted in the care plan entry being canceled and not reinstated until later. Another resident, who was alert, oriented, and dependent for personal hygiene and transfers due to hemiplegia, did not have a care plan addressing positioning, mobility, or ADL needs, despite requiring a hoyer lift for transfers and being unable to move one side of her body. Additionally, a third resident with a history of pulmonary embolism and prescribed apixaban, an anticoagulant, did not have a care plan addressing the diagnosis or the use of high-risk medication. Staff interviews confirmed that these care needs should have been included in the care plans but were not present at the time of review.