Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed the specific needs and medical interventions for multiple residents. For several residents, including those with complex medication regimens and specialized treatments, the care plans did not include problems or interventions related to their current physician orders. For example, one resident receiving enteral feeding via a gastrostomy tube did not have a care plan addressing this intervention, despite direct observation of the feeding setup and a physician's order for the feeding formula and rate. Another resident prescribed NPH insulin for Type 2 Diabetes Mellitus did not have a care plan problem or interventions related to insulin administration, as confirmed by both the RN and DON during record review. Additionally, the facility did not develop care plans for residents prescribed multiple psychotherapeutic and anticoagulant medications. One resident was receiving Remeron, Nuedexta, and divalproex sodium for various psychiatric and mood disorders, but the care plan did not address the use of these medications. Another resident was prescribed olanzapine, sertraline, trazodone, and apixaban, yet there was no documented care plan for these medications. Similarly, a resident with a history of stroke and on apixaban for anticoagulation did not have a care plan addressing the use of this medication, as verified by staff interviews and medical record review. The facility also failed to implement care plan interventions as written. In the case of a resident with hypotension, the care plan included an intervention to check blood pressure every 12 hours. However, the blood pressure summary showed that readings were not consistently documented at the required frequency. Staff interviews confirmed that the care plan interventions were not fully implemented, and the DON acknowledged these findings. These deficiencies were identified through observation, interviews, and review of medical records and facility policies.