Failure to Develop and Implement Comprehensive Care Plans for Residents with Complex Medical Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by policy and regulation. For one resident with a history of dementia, end stage renal disease, hydrocephalus, and a ventriculoperitoneal shunt, the care plan did not include any information regarding the presence of the shunt. Despite documentation in medical records and hospital discharge instructions about the shunt and its associated risks, the care plan only addressed neurological status related to hydrocephalus and seizures, omitting specific interventions or monitoring related to the shunt. For another resident with hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage, the care plan did not initially include information about the use of oxygen therapy, despite active orders for continuous oxygen via nasal cannula. The omission was confirmed through record review and staff interviews, which revealed inconsistent understanding among staff regarding responsibility for updating care plans with new orders or diagnoses. Interviews with facility staff, including the DON, MDS nurse, ADON, and unit manager, demonstrated a lack of clarity and consistency in the process for updating care plans to reflect new or ongoing medical needs. Staff acknowledged that without accurate and complete care plans, essential information about residents' conditions and required interventions might not be communicated to all caregivers, potentially impacting care delivery.