Failure to Initiate Person-Centered Care Plan for Constipation Risk
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a newly admitted resident with multiple complex medical diagnoses, including chronic pulmonary embolism, coronary heart disease, moderate pericardial effusion, and small cell lung cancer complicated by superior vena cava syndrome. The resident, who had moderately impaired cognition, was prescribed medications to prevent constipation, specifically MiraLAX and Senna, as per physician's orders. However, there was no documented evidence that a care plan addressing the risk for constipation was created or implemented for this resident. Interviews with facility staff revealed that the admitting nurse did not initiate a new care plan upon the resident's admission and instead retrieved an outdated care plan from a previous admission. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that a current care plan for constipation risk was not in place and acknowledged that it was the responsibility of the admitting nurse and other nursing staff to ensure care plans were completed. This failure was found during an abbreviated survey and was cited as noncompliance with facility policy and regulatory requirements.