Failure to Develop Comprehensive Care Plans for Residents Using CPAP and Antipsychotic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required by policy. For one resident with diagnoses including obstructive sleep apnea, hemiplegia, hemiparesis following a stroke, and legal blindness, clinical records and observations confirmed the use of a CPAP machine at bedtime per physician order. However, review of the resident's care plan revealed no documentation or respiratory care plan addressing the use of the CPAP, despite its ongoing use being documented in both annual and quarterly MDS assessments. Staff interviews confirmed the expectation that CPAP use should be included in the care plan. For another resident with dementia, behavioral disturbances, and delusional disorders, physician orders indicated the use of Seroquel for management of these conditions. Both annual and quarterly MDS assessments documented the use of antipsychotic medication, and the care area assessment summary indicated that antipsychotic medication use had triggered for care planning. Despite this, the resident's comprehensive care plan did not address the use of antipsychotic medication. Staff interviews confirmed that comprehensive care plans were expected to be developed accurately for all residents.