Failure to Develop Person-Centered Care Plans for Nutrition, Oxygen Therapy, and Epilepsy Management
Penalty
Summary
The facility failed to develop and implement person-centered care plans for several residents, resulting in deficiencies related to individualized care. For one resident with chronic pulmonary edema and acute respiratory failure, there was a significant weight loss and poor meal intake, yet the nutritional screening and care plans did not include the resident's food preferences. Interviews with the resident and staff confirmed that food preferences were never assessed or incorporated into the care plan, despite the resident expressing dissatisfaction with the food and the facility's policy requiring person-centered care planning. Three residents receiving oxygen therapy did not have care plans initiated after physician orders for oxygen were placed. These residents had varying degrees of cognitive function and required different levels of assistance, but in each case, the care plans failed to address the specifics of their oxygen therapy, including interventions, goals, and monitoring. Staff interviews confirmed the absence of these care plans and acknowledged that this omission could result in staff not knowing the full regimen for oxygen therapy or the specific needs of each resident. Another resident with epilepsy was prescribed multiple anticonvulsant medications, including Lacosamide, Keppra, and Lamictal, but no care plans were developed for these medications after the orders were placed. The DON confirmed that care plans should have been created to guide staff in monitoring for side effects and managing the resident's condition. The facility's own policies require comprehensive, person-centered care plans with measurable objectives and timeframes, but these were not followed, as evidenced by the lack of individualized care plans for the residents involved.