Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for three residents, as required by policy and regulation. For one resident with continuous high-concentration oxygen therapy and a recent history of Covid-19, there was no care plan addressing either the oxygen therapy or Covid-19 precautions, despite physician orders and ongoing respiratory care needs. Staff confirmed that these care plans were missing and acknowledged their importance for ensuring appropriate respiratory care. Another resident with a history of stroke and hemiplegia required two-person assistance for mobility and repositioning. While the care plan instructed staff to use two people for repositioning, it did not specify the frequency of repositioning, nor was there documentation that repositioning was being offered or performed as needed. A third resident with diabetes and unstable blood glucose levels had physician orders for two types of insulin but lacked a care plan addressing diabetes management. This resident reported frequent symptoms of low blood glucose and expressed concern about insulin orders. Staff interviews confirmed that care plans for these conditions were not in place, contrary to facility policy.