Failure to Develop and Implement Accurate, Comprehensive Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans consistent with its own policy and residents’ assessed needs. The facility policy required the IDT to develop comprehensive care plans with measurable objectives and timeframes, and to implement baseline care plans within 48 hours of admission. For one resident with moderately impaired cognition who used bilateral half side rails, the care plan identified a risk for entrapment and required monitoring of the resident’s safety for entrapment every shift. However, review of the medical record showed no documented evidence that this monitoring occurred, and an LVN confirmed that the intervention to monitor for entrapment every shift had not been implemented or documented in the MAR or progress notes. A second resident, cognitively intact and using a bariatric bed with built-in bilateral half side rails, also had a care plan identifying risk for entrapment/bodily injury and requiring monitoring of safety for entrapment every shift. Medical record review similarly failed to show documentation that this monitoring was performed. During interview and concurrent record review, the same LVN verified that the resident’s care plan intervention to monitor for entrapment every shift was not implemented as ordered. In both cases, the care plan interventions related to bedrail entrapment risk were not carried out or documented as required. The facility also failed to develop appropriate care plans for two additional residents’ identified conditions. One resident had a physician’s order to cleanse intergluteal cleft extending to perianal MASD with soap and water, pat dry, and apply barrier cream each day shift, but the medical record contained no care plan addressing this MASD; an RN confirmed the absence of such a care plan. Another resident had a documented midline IV access in the left upper arm, but the care plan referenced IV medication and a midline catheter in the right upper arm instead. An RN verified that the midline was actually in the left upper arm and that the care plan inaccurately identified the right upper arm. The DON was informed of and acknowledged these findings for the involved residents.
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