Failure to Develop Comprehensive, Individualized Care Plans for Residents with Lymphedema and PTSD
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific medical and psychological needs. For one resident diagnosed with lymphedema, the care plan did not include documentation of the condition or provide staff with directions regarding the use of a prescribed compression glove and wrap. Although the physician's order specified how and when to apply the compression garments, and staff were aware of the resident's frequent refusals and discomfort, this information was not reflected in the care plan. Observations and staff interviews confirmed that the resident often refused the compression garments, and staff continued to report refusals to the physician, but the care plan was not updated to guide staff actions or document refusals appropriately. Another resident with diagnoses of posttraumatic stress disorder (PTSD), major depressive disorder, and diabetes mellitus had a care plan that addressed depression but did not include individualized interventions or triggers related to PTSD. The psychiatric evaluation documented the resident experienced intrusive thoughts, flashbacks, and anxiety related to military trauma, and was prescribed medication intended to address both depression and PTSD symptoms. However, the care plan lacked any mention of trauma-based triggers or specific strategies for staff to support the resident in managing PTSD symptoms, despite facility policy requiring trauma-informed, individualized care planning. Facility policies required comprehensive, person-centered care plans that address all resident needs, including measurable objectives and timetables, and specifically called for trauma-informed care planning. The deficiencies were identified through record review, staff interviews, and direct observation, revealing that the care plans did not reflect current standards of practice or the individualized needs of the residents as required by facility policy.