Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, resulting in deficiencies related to the timely and appropriate delivery of care. For one resident with a history of pressure ulcers and high risk for further skin breakdown, there was a physician's order for bilateral cushion boots to be used while in bed for wound management and prevention. However, the boots were observed not to be applied, and the care plan did not include this intervention. Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the care plan was missing this critical intervention, and staff were not following the physician's order. Another resident with severe cognitive impairment and behavioral issues, specifically a tendency to put objects in their mouth, did not have a care plan addressing this behavior for an extended period. Staff interviews revealed that the behavior had been ongoing for at least a year, but a care plan was only developed after surveyor inquiry. The lack of a timely care plan meant that interventions to address the behavior, such as increased monitoring or physician notification, were not implemented, potentially delaying necessary care and services. Additional deficiencies included the absence of care plans for the use of antibiotics, new onset of pain, and psychotropic medication management. For example, a resident prescribed cefdinir for a urinary tract infection did not have a care plan documenting the antibiotic use, and another resident with new bilateral shoulder pain did not have a care plan or pain assessment reflecting the new pain site or the use of lidocaine patches. Staff interviews confirmed that care plans were not updated or created in response to new orders or changes in condition, leading to gaps in communication and care delivery among the interdisciplinary team.