Failure to Develop and Implement Care Plans for Substance Use, Non‑Compliance, and Antifungal Therapy
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for three residents, as required by its care planning policy. For one resident with a BIMS score indicating intact cognition, documented functional limitations in range of motion, wheelchair dependence, and a right foot amputation, multiple behavior notes and staff interviews showed that he prepared and used marijuana in his room, stayed in his car all night blocking the entrance while playing loud music, and continued to drive his car despite his amputation and an unresolved surgical wound. The Social Services Director and DON confirmed that the resident had been seen using marijuana, had nearly hit several cars in the parking lot, and that there was no care plan addressing his use of illegal substances or his driving, with the DON stating the facility did not know how to keep him safe when driving and acknowledging that the care planning policy was not followed. A second resident left the facility with an ex‑spouse and did not return for several days, and the Social Services Director confirmed there was no care plan addressing this resident’s pattern of non‑compliance or leaving the facility without informing staff. For a third resident, record review showed an active physician order for Cresemba, an anti‑fungal (anti‑viral/fungal) medication, but the Infection Prevention Nurse was unable to provide evidence of any care plan developed and implemented to address this medication therapy. The facility’s written care planning policy, which requires a comprehensive person‑centered care plan for each resident based on assessed needs, including services required and any services not provided due to exercise of resident rights, was not followed in these cases.
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