Failure to Develop Comprehensive, Person-Centered Care Plans for Catheter, Respiratory, Pain, and Anticoagulant Management
Penalty
Summary
The deficiency involves the facility’s failure to develop accurate, person-centered comprehensive care plans with measurable goals and timeframes for multiple residents. For one resident with an indwelling Foley catheter and diagnoses including infection due to ureteral stent, kidney and ureteral calculi, and obstructive and reflux uropathy, physician orders directed catheter changes every 30 days, catheter care every shift, catheter changes as needed for leakage or drainage, and catheter irrigation as needed. However, the resident’s care plan did not include any interventions addressing Foley catheter care, scheduled catheter changes, PRN catheter changes, or catheter irrigation. The MDS coordinator and the Regional Clinical Nurse (RCN) confirmed that these catheter-related interventions were not included in the care plan and that they should have been documented there. Another resident with a diagnosis of chronic pain syndrome had a physician’s order for Suboxone sublingual film to be given three times daily for chronic pain. The resident’s care plan, dated the same day as the order, did not document that the resident was receiving Suboxone or include a specific plan related to this opioid medication. During interview, the RCN confirmed that the care plan did not include a plan for Suboxone and stated that her expectation was that a specific plan would be in place for this type of medication. A third resident with COPD, chronic respiratory failure with hypoxia, a solitary pulmonary nodule, and dependence on supplemental O2 had orders for PRN Albuterol-Budesonide inhalation aerosol, O2 via nasal cannula at 6–8 L/min, elevation of the head of bed or use of a pillow for shortness of breath, and weekly changes of O2 tubing and concentrator filter. An LPN reported that this resident used a special high-flow nasal cannula connected to two O2 concentrators. The care plan did not document the need for the special high-flow nasal cannula, the use of two concentrators, weekly replacement of nasal cannula and concentrator filter, head-of-bed elevation or pillow use, or the PRN Albuterol-Budesonide order. The ADON confirmed these omissions and stated that all respiratory interventions should be on the care plan. A fourth resident, readmitted with a diagnosis of pulmonary embolism and an order for Apixaban twice daily as a blood thinner, also lacked care plan documentation that the resident was taking Apixaban for a history of pulmonary embolism or that addressed the risks associated with this medication; the RCN confirmed the absence of a care plan for Apixaban and stated that a specific plan including risks was expected.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.