Failure to Implement and Document Comprehensive Care Plans for Pain and Bleeding Risk
Penalty
Summary
The facility failed to implement care plan interventions and adequately monitor and record pain characteristics for a resident with chronic pain. The resident, who had multiple diagnoses including COPD, acute respiratory failure, dysphagia, Parkinson's disease, and polyneuropathy, was care planned for chronic pain with specific interventions to monitor and document pain characteristics every shift and as needed. Despite this, documentation was missing regarding the location of pain when narcotic pain medication was administered on several occasions. The resident reported knee pain and, during observation, complained of severe pain in the left hip, thigh, and knee, with limited movement in the left lower extremities. The facility's policy required comprehensive, person-centered care planning, but these interventions were not consistently implemented or documented. Additionally, the facility failed to develop and implement a comprehensive, person-centered care plan for another resident who was receiving anticoagulant therapy and was at risk for bleeding. This resident had a history of tracheostomy, atrial fibrillation, and sepsis, and was cognitively impaired, unable to make decisions. The resident was prescribed both Amiodarone and Eliquis, which have a known drug interaction that increases the risk of bleeding. Despite a documented episode of blood in the urine and vomiting, and a pharmacist's review noting the increased risk, there was no care plan created to address the risk of bleeding within the required timeframe after the medications were ordered or after the change in condition. Interviews with nursing staff confirmed that care plans should have been created and implemented for both pain management and risk of bleeding, in accordance with facility policy. The lack of timely and comprehensive care planning and documentation resulted in unmet individualized needs for both residents, as identified through observation, interview, and record review.