Failure to Develop and Implement Comprehensive, Accurate Care Plans for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, individualized care plans with measurable goals and interventions for multiple residents. For one resident who returned from the hospital on 1/24/2026, the surveyor observed an IV antibiotic mini bag at the bedside, but record review showed there was no comprehensive care plan addressing the IV antibiotic therapy or care of the IV access site. The same resident had an incomplete care plan for a mid‑back surgical site and dermatitis that lacked goals and interventions. The DON stated that the care plan had not been reactivated when the resident returned from the hospital. Another resident had an active care plan that included interventions for monitoring signs and symptoms of abnormal bleeding and bruising related to anticoagulant use, but record review showed there were no active or discontinued physician orders for any anticoagulant medication during the resident’s stay. The hospital discharge summary indicated a history of DVT and that the resident was not anticoagulated. The DON acknowledged that the clinical team was responsible for implementing and updating care plans, yet the care plan still contained anticoagulant‑related interventions that did not match the resident’s actual medication regimen. A further resident with a documented fall on 11/10/2024 and a diagnosis of history of falling did not have any problem, goal, or interventions in the comprehensive care plan for an actual fall or risk for falls. This same resident had a physician order for Eliquis 5 mg twice daily for atrial fibrillation, but there was no comprehensive care plan addressing the anticoagulant medication or the cardiac arrhythmia. In addition, another resident with a primary diagnosis of rheumatoid arthritis, constant pain, and multiple standing and PRN pain medications (including Hydrocodone‑Acetaminophen, Lyrica, Lidocaine patch, Capsaicin, and Extra Strength Tylenol) had no pain management care plan. The initial care plan update completed 72 hours after admission did not mention pain or pain relief measures, and a progress note indicated no medical or nursing staff attended that care plan meeting. When questioned, an employee stated they did not know why pain management was not included in the care plan.
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