Failure to Implement Care Plans for Non-Pharmacological Interventions and Restricted Limb Precautions
Penalty
Summary
The facility failed to develop and implement complete care plans that addressed all the needs of several residents, specifically regarding non-pharmacological interventions for behavioral symptoms and restricted limb precautions for those with dialysis access. For one resident with a physician's order for PRN Ativan due to behaviors such as resisting care, physical aggression, and agitation, the care plan included non-pharmacological interventions. However, documentation showed that 29 doses of Ativan were administered without recording the specific behaviors that prompted use or the non-pharmacological interventions attempted prior to medication administration. Additionally, multiple residents with physician's orders to avoid blood pressure measurements or blood draws in limbs with dialysis fistulas or shunts had care plans that were either not implemented or not developed to reflect these restrictions. Despite clear orders and care plan interventions, blood pressure readings were repeatedly documented as being taken in the restricted limbs for these residents over an extended period. In one case, the care plan did not include the necessary intervention at all, and in others, the intervention was listed but not followed in practice. These deficiencies were identified through record reviews and staff interviews, which confirmed that the care plans were either incomplete or not followed as required. The Director of Nursing acknowledged the failures in documentation and care plan implementation when notified during the survey process.