Failure to Develop and Implement Required Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents with specific care needs. For one resident with a history of heart failure and blood clots, who was receiving Apixaban for DVT prophylaxis, there was no care plan addressing anticoagulant monitoring, despite documentation of the medication being administered multiple times. Both a licensed nurse and the Minimum Data Set Coordinator confirmed the absence of a care plan for anticoagulation, acknowledging its importance due to the resident's risk for bleeding. Another resident, re-admitted for surgical aftercare and with severe cognitive impairment, was observed using both bed and wheelchair alarms. Certified Nursing Assistants and a licensed nurse verified the use of these alarms and stated that alarms were expected to be in use at all times. However, review of the medical record revealed no care plan for the use of either alarm, and staff confirmed that such a care plan should have been in place, especially following the resident's re-admission from the hospital. A third resident, with a memory problem and a history of joint replacement, was also found to be using a bed alarm to prevent falls. Staff interviews and record reviews confirmed the presence of the bed alarm but revealed that no care plan had been developed for its use. The Director of Nursing and other staff acknowledged the importance of care plans for summarizing health conditions and interventions, and confirmed the lack of a care plan for this resident's bed alarm. Facility policy requires comprehensive, person-centered care plans with measurable objectives and timetables for each resident, which were not in place for these three residents.