Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were developed and implemented to address residents' specific medical needs and significant changes in condition. One resident receiving oxygen therapy did not have this intervention included in their care plan, despite documentation in the Minimum Data Set (MDS) and direct observation of oxygen use. Additionally, the same resident had an active diagnosis of mood disorder and was prescribed risperidone, but neither the diagnosis nor the medication was addressed in the care plan. Another resident was admitted to hospice services following a significant change in condition, as indicated by physician orders and MDS documentation. However, there was no care plan addressing hospice or end-of-life care needs until several weeks after hospice admission, and only after the survey team arrived at the facility. Staff interviews confirmed that care plans should be updated promptly following significant changes in condition, but this did not occur in this case. A third resident, admitted for skilled rehabilitation and later transitioned to long-term care, did not have quarterly care plan meetings conducted as required. After the initial interdisciplinary care conference, there was no evidence of subsequent care plan meetings or documentation, despite ongoing concerns related to the resident's hearing and vision. The facility was unable to provide records of any additional care plan meetings after the initial conference.