Failure to Develop and Implement Person-Centered Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans for three residents with significant medical diagnoses. For one resident, there were no care plans addressing hypertension, depression, or anticoagulant therapy, despite physician orders for multiple medications to manage these conditions. This omission was confirmed by a licensed nurse, who acknowledged that care plans should have been in place to guide care and interventions for these health issues. Another resident was admitted with diagnoses including hypertension, chest pain, and a history of stroke, but did not have care plans related to these conditions. Physician orders included medications for stroke prevention, hypertension, and chest pain, yet the care plans did not reflect these needs. The Minimum Data Set Assistant and the Director of Nursing both confirmed the absence of appropriate care plans, attributing the lapse to a transition in facility ownership and acknowledging that care plans should have been updated to reflect the resident's current health status. A third resident, admitted with diabetes and prescribed medications to control blood sugar, also lacked a care plan for diabetes until a significant increase in blood sugar was noted. The Director of Nursing confirmed that a care plan should have been in place to address the resident's diabetes and that the care plan should have included specific interventions for the resident's health concerns. The facility's policy requires a written care plan for each resident at admission, based on a comprehensive assessment, and updated as needed, but this was not followed for the residents in question.