Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were developed and implemented for several residents, leading to deficiencies in meeting their medical and nursing needs. Resident #10, who had multiple sclerosis, diabetes mellitus type 2, and pressure ulcers, did not have care plan interventions for their pressure ulcers until a month after admission, despite having stage III and unstageable pressure ulcers. The Director of Nursing acknowledged the lack of interventions and added them only after the surveyor's request. Resident #25, diagnosed with dementia and stroke, required assistance with oral hygiene but did not have a care plan for denture care. The care plan lacked documentation of the resident's dentures, which was necessary for proper hygiene and to prevent bacterial growth. Interviews with nursing staff revealed that care plans had not been updated recently, and there was a lack of awareness about the resident's denture needs. Residents #36 and #41 were involved in an alleged altercation, but their care plans did not include interventions to prevent future incidents. The facility's investigation documented the altercation, but no care plan updates were made to address the issue. Additionally, Resident #43's care plan was missing focus areas, goals, and interventions for various diagnoses and treatments, while Resident #65's care plan lacked documentation for bladder incontinence, falls, and other critical areas. The Director of Nursing and other staff members acknowledged the deficiencies and the importance of timely and comprehensive care planning.
Plan Of Correction
Plan of Correction: Approved January 6, 2025 1. Resident #10's careplan was reviewed by IDT Team and was updated to reflect wounds. The admissions nurse was reeducated on having careplan in place upon admission. Resident #25's careplan and closet care plan was reviewed by IDT and careplan was updated to reflect denture care. Resident #36's and resident #41 had careplan reviewed by IDT for behaviors by IDT and plan was updated to reflect residents status. Resident #43's careplan was reviewed by IDT and careplan and closet care plan was updated to reflect current status. Nurse who did residents admission was updated on policy and procedure on careplans by Director of Nursing. Resident #65 careplan and closet careplan was reviewed by IDT and updated to reflect current status. All residents Careplans were reviewed by RN for updated careplans reflecting current status. 2. All residents are at risk for deficient practice of not completing the careplan on admission and updating the careplan during the 21 day admission period as well as Quarterly and Annually to reflect changes occurred by resident. 3. Policy and procedure for baseline careplans and comprehensive careplan was reviewed by Director of Nursing. No changes were made to policy. 4. Outside consultant educated IDT on comprehensive careplan process and baseline careplanning. All licensed nurses were educated on careplan and closet care plan process by RN Educator. The Director of Nursing will be educated on the comprehensive careplan policy and procedure by the Consultant. 5. All new admissions will be audited weekly for 4 weeks and monthly for 6 months to ensure all areas are careplanned and on closet careplan for staff to provide care to residents. CCP will be audited by MDS coordinator to ensure CCP reflects all areas weekly for 1 month and monthly for 6 months. Any deficient practices will be corrected and brought to QAPI for further review. Person Responsible: Director of Nursing