Failure to Develop Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for four residents, as required by facility policy and professional standards. Specifically, one resident with an indwelling urinary catheter did not have a care plan addressing catheter care, despite physician orders detailing the need for ongoing catheter management and enhanced barrier precautions. The MDS Coordinator confirmed that no care plan was in place for this resident, acknowledging that such a plan should have been completed following the admission assessment. Two other residents who were receiving oxygen therapy also lacked care plans addressing their oxygen use. Both residents had documented orders for oxygen administration and were observed receiving oxygen during the survey. Staff interviews confirmed that the care plans did not include focus areas or interventions related to oxygen therapy, even though this was documented in their assessments. The DON and MDS Coordinator both verified that oxygen use should have been included in the care plans for these residents. A fourth resident, who was prescribed antianxiety, antidepressant, and hypoglycemic medications, did not have a care plan addressing the use of these psychotropic and high-risk medications. The resident's medication use was documented in the MDS assessment, but the care plan lacked any focus areas, goals, or interventions related to these medications. Multiple staff members, including LPNs and the DON, confirmed that interventions for these medications should have been present in the care plan and were unable to explain why they were missing.