Failure to Develop and Implement Comprehensive Care Plan Results in Resident Harm and Death
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all of a resident's needs, resulting in significant harm. Upon admission, the resident had multiple complex diagnoses, including narcolepsy with cataplexy, schizophrenia, diabetes requiring sliding scale insulin, osteoporosis, frequent falls, and recent fractures. Despite clear hospital discharge orders for specific medications and interventions, including antipsychotic management, blood glucose monitoring four times daily, and sliding scale insulin, these orders were not implemented. The care plan did not reflect the resident's actual urinary tract infection, omitted interventions for the treatment of the UTI, and failed to address the use of sliding scale insulin or the need for frequent blood glucose checks. As a result, the resident experienced multiple episodes of hyperglycemia without appropriate monitoring or insulin administration. The care plan also failed to identify or address safety risks associated with the resident's narcolepsy with cataplexy, the use of high-risk medications, and the complications of a subdural hematoma following a fall. The resident's fall risk assessment contained inaccuracies, underestimating the number of high-risk medications and predisposing conditions. The care plan did not include interventions for increased fall risk due to the resident's diagnoses or medication changes, nor did it address the management of withdrawal symptoms from the abrupt cessation of Seroquel, which led to behavioral changes such as hallucinations, anxiety, and wandering. Despite documentation of these changes and repeated incidents of self-ambulation and falls, the care plan was not updated to include additional safety interventions or increased supervision. Following a fall that resulted in a subdural hematoma and subsequent complications, the care plan still was not revised to address the resident's new diagnoses or increased care needs. The resident continued to experience falls, behavioral disturbances, and medical complications, including a worsening hematoma and uncal herniation, without appropriate updates to the care plan or implementation of necessary interventions. Ultimately, the resident died as a result of complications from the fall and subdural hemorrhage. This deficiency was cited as immediate jeopardy and was a repeat finding for the facility.