Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for three residents with specific clinical needs. One resident with a diagnosis of post-traumatic stress disorder (PTSD), depression, anxiety, and dementia did not have a care plan addressing PTSD, despite staff interviews confirming that certain care approaches could trigger the resident's PTSD symptoms. The absence of a care plan for PTSD was acknowledged by both nursing and social services staff, as well as the Director of Nursing, who stated that such a plan was necessary for staff to understand and meet the resident's needs. Another resident, admitted with morbid obesity, bilateral artificial knee joints, and anxiety, experienced intentional weight loss as part of a personal health goal. The resident's weight loss was documented in the medical record and discussed with the registered dietician and dietary staff. However, there was no care plan in place to guide staff on monitoring the weight loss, ensuring it remained within safe parameters, or supporting the resident's goals, as confirmed by nursing staff and the DON. A third resident, diagnosed with Parkinson's disease, dementia, and muscle weakness, was receiving Restorative Nursing Aide (RNA) services for bilateral upper extremity active range of motion exercises. Despite active physician orders and ongoing RNA interventions, there was no care plan outlining the goals or interventions for these services. Nursing staff and the DON confirmed the absence of a care plan, noting that such documentation is necessary to ensure proper care and to track the resident's progress.