Failure to Develop Individualized Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents with specific clinical needs. For one resident with end stage renal disease and dependence on dialysis, the physician ordered a daily fluid restriction of 1,000cc. Despite this order being documented in the resident's records, there was no care plan created to address the fluid restriction. Both the LVN and the DON confirmed that a care plan should have been in place to guide staff in managing the resident's fluid intake and to prevent complications related to fluid overload. Another resident, who was readmitted with diagnoses including cellulitis, long-term antibiotic use, and a deep incisional surgical infection, was receiving intravenous antibiotics as ordered by the physician. The medication administration record confirmed that the resident was receiving IV Vancomycin and Ceftriaxone for a surgical wound infection. However, there was no individualized care plan initiated to address the administration of IV antibiotics. The DON and the MDS nurse both acknowledged that a care plan should have been developed to ensure all staff were aware of the resident's needs, goals, and interventions related to IV therapy. A third resident, with a history of pressure ulcers, abnormal posture, and muscle weakness, was observed using a bolster low air loss mattress. While the resident had a care plan for the use of a low air loss mattress for skin and wound maintenance, there was no care plan specifically addressing the use of the bolster feature. Staff interviews and record reviews confirmed the absence of a care plan for the bolster mattress, which was used to prevent the resident from sliding or falling out of bed. The DON verified that a care plan should have included monitoring the placement of the bolster to ensure safety and prevent additional skin issues.