Failure to Develop and Implement Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical needs. Despite the resident having a range of diagnoses including hypertension, colitis, pressure ulcers, edema, and recent orthopedic surgery, the care plan only addressed fall risk and did not include measurable objectives or interventions for other significant health issues. Physician orders and medication administration records indicated active treatment for these conditions, but these were not reflected in the resident's care plan. Interviews with facility staff revealed a lack of clarity and communication regarding responsibility for care plan development. The MDS nurse, who was responsible for initiating care plans, did not complete sections related to skin and pressure ulcers, citing remote work and lack of direct resident contact. The ADON, who conducted wound rounds, did not contribute to the care plan, believing it was outside her scope. The DON, who was on vacation during the resident's stay, stated that care plan completion was a shared responsibility but was not informed of the missing care plan sections. Other staff, including the admissions nurse and social worker, described their roles as limited to data collection or room preparation, not care plan development. Family interviews indicated that concerns raised during a care plan meeting, such as the resident's pressure wound, diarrhea, and need for specific interventions, were not addressed in the care plan or acted upon before discharge. The lack of a comprehensive care plan resulted in the resident's needs not being fully identified or met, as evidenced by ongoing issues with wound care, bowel management, and medication administration. Facility policy required comprehensive care plans with measurable, time-limited goals, but this was not followed in the resident's case.