Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions. The resident, a cognitively intact female, was admitted with diagnoses including chronic obstructive pulmonary disease, heart failure, hypertension, diabetes mellitus, muscle weakness, and septicemia. Her assessment indicated she required substantial to maximal assistance with activities of daily living (ADLs) and was receiving several medications, including antidepressants, antibiotics, diuretics, hypoglycemics, and opioids. Upon review, the resident's care plan lacked measurable objectives and timeframes for several critical areas. While the care plan addressed code status and fall risk with some goals and interventions, it did not include any goals or interventions for diabetes management, use of antidepressant medication, opioid use, insulin administration, or ADL care. Physician orders documented the administration of multiple medications, including insulin and antidepressants, but these were not reflected in the care plan as required. Interviews with facility staff, including the ADON and DON, confirmed that the care plan was incomplete and did not address all areas triggered by the resident's assessment. The ADON acknowledged responsibility for ensuring the care plan was accurate and complete, and both the ADON and DON recognized that incomplete care plans could result in staff not providing the necessary care. Facility policy required comprehensive care plans with measurable objectives and timetables to be developed within seven days of the assessment, but this was not followed in this case.