Failure to Implement Care Plan Interventions for Thyroid Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with hypothyroidism and severe cognitive impairment. The resident, an older male with diagnoses including paralytic syndrome, traumatic brain injury, and hypothyroidism, required dependent assistance with all ADLs and had a BIMS score of 03, indicating severe cognitive impairment. His comprehensive care plan, dated 06/12/2025, identified hypothyroidism and included an intervention to monitor thyroid function tests per MD order and notify the MD of abnormal lab values. Physician orders dated 09/21/2024 required a TSH lab to be drawn every six months, and the last documented TSH result in the EHR was from 03/17/2025. No subsequent TSH labs were documented after that date, meaning the ordered lab due in September 2025 was not obtained. During interview, the DON acknowledged that the resident should have had a TSH drawn in September 2025 and that it had not been done, attributing the lapse to a change in lab services and incorrect transcription of the order. The Administrator stated her expectation that all care plan interventions be followed and acknowledged that not following the care plan could lead to lack of individualized care. The facility’s policy on comprehensive care planning stated that the facility will establish, document, and implement care and services to assist each resident in attaining or maintaining their highest practicable quality of life.
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