Failure to Develop and Implement Care Plan for Change of Condition
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, resident-centered care plan for a resident who experienced a change of condition due to a broken tooth. The resident, who had a medical history including palliative care, alcoholic cirrhosis of the liver with ascites, and type 2 diabetes mellitus with complications, was observed to be alert, oriented, and comfortable. The resident confirmed that the broken tooth had already been extracted. However, review of the care plans revealed that no care plan was created at the time of the change of condition to address the broken tooth, including necessary interventions and monitoring. Interviews with the DON confirmed that a care plan should have been initiated for the resident's broken tooth to ensure proper monitoring, interventions, and follow-up, but this was not done. Review of facility policies indicated that both episodic and comprehensive care plans are required for acute changes in condition, with measurable goals and timeframes. Despite these policies, the facility did not create or implement a care plan for the resident's dental issue, resulting in a failure to address the resident's needs as required.