Failure to Implement Comprehensive Care Plans and Required Interventions
Penalty
Summary
Facility staff failed to implement comprehensive care plans for six residents, resulting in multiple deficiencies related to the delivery of care and safety interventions. For two residents with cognitive impairment and nicotine dependence, staff did not provide required smoking aprons or direct supervision while the residents smoked, despite care plans and facility policy specifying these interventions. Observations showed these residents smoking independently, without protective equipment or staff oversight, and using personal lighters, contrary to documented care plan interventions. For three residents, staff did not administer medications as ordered or document reasons for missed doses. Medication administration records (MARs) and electronic MARs (eMARs) revealed blank entries or notes indicating medications were not available, but there was no evidence of physician notification or follow-up documentation. This included missed doses of antipsychotic, antihypertensive, antiplatelet, diabetic, and pain medications, as well as intravenous antibiotics and other critical therapies. In some cases, nurse interviews confirmed that the care plan was not consistently followed or that documentation was incomplete. Additionally, staff failed to provide wound care treatments and complete required weekly wound assessments for several residents with pressure injuries or surgical wounds. Treatment administration records (TARs and eTARs) showed missed wound care on multiple dates, and there was a lack of documentation regarding the missed treatments or wound measurements. Interviews with nursing staff and administrators indicated lapses in wound tracking and assessment processes, particularly following staff turnover and the departure of a wound care nurse practitioner.