Failure to Develop and Implement Comprehensive, Measurable Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for several residents, as required by policy. For one resident with a history of cerebral infarction and severe cognitive impairment, the care plan and aide Kardex specified the need for two-person assistance with bed mobility and transfers. However, a certified nurse aide provided care alone, resulting in the resident falling from bed and sustaining injuries, including bruising and a laceration. The incident was documented by the Director of Nursing, and it was confirmed that the required two-person assist was not provided. Another resident with dementia, a femur fracture, and repeated falls had a physician order for a velcro alarm seatbelt in the wheelchair, with instructions for scheduled release and monitoring of the resident's ability to self-release. There was no evidence in the care plan addressing the use or release schedule of the lap/seat belt, and staff were unaware of the order or procedures related to the restraint. Observations showed the resident wearing the seatbelt for extended periods and being unable to remove it on command, with staff confirming the lack of guidance in the care plan or Kardex. A third resident with Alzheimer's disease, contractures, and muscle weakness had physician orders for a knee abductor roll and rolled gauze hand protectors. The care plan did not address these devices, and observations revealed the resident without the prescribed supports. Staff interviews indicated that therapy recommendations were not incorporated into the care plan, and the nurse manager could not locate documentation for these interventions, attributing the omission to a transition between electronic medical records. Additionally, care plans for activities and safety checks were missing or not implemented for other residents reviewed.