Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four out of five sampled residents, as required by their own policies and regulatory standards. For one resident with a diagnosis of pneumonia, there was no care plan created to address the infection, despite physician orders for antibiotic treatment and documentation of severely impaired cognitive skills. Both the Infection Preventionist and nursing leadership confirmed that a care plan should have been developed to guide nursing care and ensure continuity. Another resident, who was prescribed azithromycin for bronchitis, also did not have a care plan addressing the use of this antibiotic. The resident had a history of Parkinson’s disease, dementia, and fluctuating decision-making capacity. Nursing leadership acknowledged that the absence of a care plan for antibiotic use could result in a lack of guidance for staff and potentially impact the resident’s care. A third resident, identified as high risk for falls and with a history of Alzheimer’s disease and osteoporosis, refused to remove a wheelchair from atop a floor mat designed to prevent injury from falls. Although staff were aware of the risks and the resident’s refusal, there was no care plan documenting this behavior or interventions to address it. Additionally, for a fourth resident involved in a resident-to-resident altercation, the care plan addressing the incident was not developed until the day after the event, rather than immediately. Staff interviews confirmed that timely care planning was not performed, which could have delayed appropriate interventions and communication among the care team.