Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, as identified through record reviews, resident interviews, and staff interviews. One resident, who was a hemodialysis patient, had recently returned from the hospital after the placement of an arteriovenous fistula (AVF) in her left upper arm. Despite this significant change in her medical status, her care plan did not include any mention of the AVF, and the DON confirmed that no care plan had been developed for this new condition. Additionally, the resident reported discomfort with her current dialysis port and described her awareness of the AVF, but staff interviews indicated that no specific interventions or monitoring were being performed for the AVF since it was not yet in use. Another resident with bilateral knee contractures did not have these contractures documented in their care plan, a fact confirmed by the DON. A third resident's care plan was found to be incomplete, lacking personalized details regarding the assistance needed for activities such as toileting, transfers, and bathing, with several blanks left unfilled. These findings demonstrate that the facility did not ensure care plans were updated or completed to reflect residents' current needs and conditions.