Failure to Implement Comprehensive Care Plans and Physician Orders
Penalty
Summary
Facility staff failed to implement comprehensive care plans for multiple residents, resulting in deficiencies related to wound care, pressure injury prevention, infection control, medication education, and tracheostomy care. For one resident with severe cognitive impairment and immobility, staff did not follow wound nurse practitioner recommendations for treating a right heel and right anterior lower leg pressure injury. Orders for recommended treatments, such as skin prep and specific wound dressings, were not entered or implemented in a timely manner, and documentation in the electronic treatment administration record (eTAR) did not reflect the recommended care until weeks after the initial assessment. Interviews with staff revealed a breakdown in communication and order entry processes between the wound nurse practitioner, facility wound nurse, and primary care physician. Another resident with multiple pressure injuries on the buttocks was not turned or repositioned according to the care plan, which required assistance every two hours. Observations showed the resident remained in the same position for extended periods, and the resident reported not being repositioned overnight. The care plan specifically noted the need for monitoring, reminders, and assistance with turning and positioning, but these interventions were not consistently provided. Additional deficiencies included failure to implement contact precautions for a resident with shingles, as staff wore gloves but not gowns and posted the incorrect precaution signage. For a resident with a tracheostomy, required care was not documented as completed on several shifts, as evidenced by blank entries in the respiratory administration record. Another resident receiving anti-anxiety medication did not receive documented education about the risks, benefits, and side effects of the medication, as required by the care plan. In each case, the facility's failure to follow individualized care plans and physician or practitioner recommendations led to lapses in care delivery and documentation.