Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address the specific needs of three residents. For one resident with dementia and peripheral vascular disease, clinical records showed podiatry recommendations for wound care, including daily application of betadine and gauze, monitoring for worsening gangrene, and daily measurements. Additional podiatry orders included continued antibiotics and specific dressing changes following toenail removal. Despite these documented needs and orders, there was no care plan in place for wound care or foot care as confirmed by the Director of Nursing. Two other residents were also found to lack appropriate care plans for their primary diagnoses. One resident with dementia and behavioral disturbances did not have a care plan addressing dementia, and another resident with bipolar disorder did not have a care plan for this mental health condition. These omissions were identified through clinical record reviews and care plan audits, indicating a failure to ensure that care plans were developed and implemented to meet the residents' assessed needs.