Failure to Develop Specific and Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop specific and resident-centered care plans for three sampled residents, resulting in care plans that did not adequately address the residents' individual needs. For one resident with hypertensive heart disease and generalized muscle weakness, the care plan only instructed staff to administer medication and diet as ordered, without specifying the medication name or providing detailed interventions. The Infection Preventionist Nurse (IPN) confirmed that the care plan lacked specificity and should have included the medication name. Another resident with a history of pneumonia, sepsis, and GERD had care plans that were not updated to reflect current conditions. The care plan for sepsis related to pneumonia remained active even though the resident was no longer receiving antibiotics or had active pneumonia. The IPN acknowledged that the care plan should have been discontinued after the last dose of antibiotics and that failure to update care plans could lead to medication errors and negatively affect resident care. The care plan for GERD also lacked specificity, as it did not list the medication by name. A third resident with dyspepsia and muscle weakness had a care plan that instructed staff to provide diet as ordered, administer medication as ordered, and frequently check for reassurance, but again did not specify the medication. The IPN and Director of Nursing (DON) both stated that care plans should be individualized, specific, and updated promptly to reflect changes in the resident's condition or treatment. The facility's policy required person-centered, comprehensive, and interdisciplinary care planning, but the reviewed care plans did not meet these standards.