Failure to Develop and Implement Comprehensive Care Plans for Residents with Hospice and Catheter Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans to address all identified needs for two residents. For one resident with diagnoses including cerebral palsy and muscle wasting, who was dependent for all activities of daily living and receiving hospice care, the care plan did not include any reference to hospice services, despite a physician order for hospice admission. The omission was confirmed by both the DON and the Administrator, who acknowledged that the care plan for hospice was overlooked during a period when the facility was without an MDS Nurse and care plan responsibilities were being managed by the DON and ADON. For another resident with chronic diastolic heart failure and type 2 diabetes, who was dependent for most ADLs and had an indwelling urinary catheter due to urinary retention, the care plan did not address the presence of the catheter or required catheter care. This was confirmed through record review and interviews with the DON and Administrator, who both stated that the care plan for the catheter was missing. The facility's policy requires comprehensive care plans to include measurable objectives and timeframes for all identified needs, but this was not followed in these cases.