Failure to Develop Comprehensive Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents with complex medical and behavioral needs. For one resident with severe cognitive impairment and a diagnosis of PTSD, the care plan did not address the use of a low bed as a physical restraint, nor did it include a focus, goal, or intervention related to PTSD until several months after admission. Staff interviews confirmed that a care plan for the low bed and PTSD should have been in place upon admission, but these were not initiated until much later. Another resident with severe cognitive impairment and a diagnosis of dementia was prescribed an antianxiety medication, Lorazepam, but the care plan did not address the use of this medication or the resident's dementia diagnosis. The care plan for the antianxiety medication was not initiated until over a month after the medication was ordered, and there was no care plan focus on dementia at all. Staff acknowledged that both the medication and dementia diagnosis should have been included in the care plan from the time of prescription and admission, respectively. A third resident, moderately cognitively impaired and diagnosed with chronic atrial fibrillation, was prescribed an anticoagulant medication, Dabigatran Etexilate Mesylate. The care plan did not include any focus or intervention related to the use of this anticoagulant, despite ongoing administration of the medication. Staff interviews confirmed that the anticoagulant should have been addressed in the care plan, but it was not present.