Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in multiple areas of care not being addressed. For one resident, the care plan did not include focus areas or interventions for full code status, allergies, impaired thought processes, cellulitis, and nutritional problems, including the use of a feeding tube. This resident had a history of cellulitis in both lower limbs, bipolar disorder, mild protein-calorie malnutrition, and cognitive communication deficits, and was dependent on staff for most activities of daily living. Despite these complex needs, the care plan lacked measurable objectives and timeframes for these critical issues. Another resident, who had diagnoses including Type 2 Diabetes Mellitus, severe protein-calorie malnutrition, metabolic disorder, dysphagia, and cognitive communication deficit, also did not have a care plan focus area for her feeding tube, despite physician orders for enteral feeding. This resident required total assistance for all activities of daily living and was observed with a feeding tube in use, but the care plan did not reflect this intervention or provide guidance for staff. Interviews with facility staff, including the DON and MDS nurses, confirmed that these omissions were not in line with facility policy or regulatory requirements. Staff acknowledged that the care plans should have included these areas and that the lack of comprehensive care planning could result in residents not receiving necessary care. Record reviews and staff statements indicated that the care plans were not updated to reflect the residents' current needs and physician orders.