Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required. For one resident, the care plan did not address critical needs such as dialysis (including shunt monitoring and care), diabetic care (including blood sugar checks, dietary restrictions, and insulin needs), glaucoma, seizure management, mental health needs, wound care, blood pressure monitoring, ADL assistance, and vaccine status. This resident had multiple diagnoses including dialysis dependence, epilepsy, diabetes, depression, glaucoma, and heart failure, and was receiving a complex medication regimen and therapies, yet the care plan only included code status, allergy, and personal care/activity preferences. Another resident, with a history of stroke, dementia with behaviors, malnutrition, hypothyroidism, and on hospice care, also lacked a comprehensive care plan. The care plan did not address the resident's mental health and behavioral issues, pain management, high blood pressure, hospice services, ADL needs, communication, cognitive status, nutritional status, risk to skin integrity, incontinence, or vaccination status. This resident had severe cognitive impairment, was at risk for pressure sores, had a catheter, and required substantial assistance with ADLs, but the care plan only included code status, allergies, personalized care preferences, and a fall prevention plan. A third resident, with multiple chronic conditions including stroke, diabetes, depression, kidney disease, hypertension, and vision impairment, also did not have a care plan addressing code status, mental and behavioral needs, kidney disease, pain, dietary or fluid restrictions, low thyroid, hypertension, diabetic care, respiratory needs, ADL needs, risk of falls, range of motion impairment, vision needs, or vaccination status. Interviews with facility staff revealed that there had been significant turnover in management and MDS coordinators, resulting in incomplete and outdated care plans. Staff acknowledged that care plans were lacking and that the process for developing and updating them had not been consistently followed.