Care Plans Incomplete for Residents with Multiple Diagnoses
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that included all current diagnoses for two residents. For one resident, the care plan did not address diagnoses such as non-Alzheimer's disease, paraplegia, transient paralysis, acute embolism and thrombosis of the lower extremity, obstructive and reflux uropathy, and retention of urine. For another resident, the care plan omitted multiple diagnoses, including panic disorder, dizziness, generalized muscle weakness, inflammatory liver disease, chronic viral hepatitis C, a history of MRSA, vestibular disorder, benign prostatic hyperplasia, urinary retention, obstructive sleep apnea, hypertension, hyperlipidemia, bilateral age-related nuclear cataract, dry eye syndrome, GERD, and constipation. These omissions were confirmed by the DON following record reviews.