Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in deficiencies related to the delivery of necessary care and services. For one resident with cerebrovascular disease, major depressive disorder, and vascular dementia, the facility did not implement the care plan for a wheelchair pad alarm as ordered by the physician, and failed to develop a care plan addressing the resident's behavior of removing the bed pad alarm. Observations confirmed the resident was without the required wheelchair pad alarm on multiple occasions, and staff interviews acknowledged the absence of a care plan for the resident's removal of the bed alarm, despite documented falls and incidents related to this behavior. Additionally, the same resident was prescribed Ativan and Haldol for anxiety and related symptoms, but there was no care plan developed for the use of these medications. Staff interviews and record reviews confirmed the lack of a care plan to monitor the administration and effects of these medications, contrary to facility policy requiring measurable objectives and timeframes for all care interventions, including medication management. For another resident with Alzheimer's disease and a history of falls, the facility did not develop or implement a comprehensive care plan for the use of a restraint pad/tab alarm, despite the resident being at high risk for falls and the device being in use. Similarly, a third resident with chronic osteomyelitis, diabetes, and MRSA infection was prescribed an antibiotic (Cephalexin), but no care plan was developed or implemented to monitor the effectiveness or adverse effects of the medication. Staff interviews confirmed the absence of care plans for these interventions, and facility policies require comprehensive care plans for all such treatments and devices.