Failure to Develop Comprehensive Care Plan for Resident with JP Drains
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with two right abdominal Jackson Pratt (JP) drains. Despite the resident's complex medical history, including cellulitis of the lower extremity, malignant neoplasm of the colon, and heart failure, and the need for maximal assistance with personal hygiene, showers, and lower body dressing, the care plan did not address the presence or management of the JP drains. This omission was identified through observation, interview, and record review, which confirmed that the care plan lacked measurable objectives and timetables related to the JP drains. Interviews with facility staff, including an LVN and the DON, confirmed that the care plan should be resident-centered and include specific goals and interventions for all resident conditions, but the JP drains were not included. The facility's own policies require the development and implementation of person-centered, comprehensive care plans that address each resident's medical, physical, mental, and psychosocial needs. The failure to include the JP drains in the care plan was acknowledged by staff and was found to place the resident at risk for insufficient provision of care and services related to the JP drains.