Deficiency in Comprehensive Care Plan Documentation
Penalty
Summary
The facility failed to ensure the development and implementation of a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the care plan for a resident did not document the use of oxygen and a nebulizer, despite the resident being observed with oxygen in place and having an order for oxygen and nebulizer treatments in the electronic health record. The resident was admitted with diagnoses including hypertension, paroxysmal atrial fibrillation, and supraventricular tachycardia, and was cognitively intact, able to understand and be understood by others. The facility's policy required a written care plan to be developed upon admission and reviewed within 48 hours, with completion by the first care plan meeting within 14 days. However, the care plan dated 11/21/2024 lacked documentation of the resident's oxygen use, despite an order for continuous oxygen and nebulizer treatments being present in the electronic health record. Interviews with facility staff, including a Licensed Practical Nurse and the Assistant Director of Nursing, confirmed the absence of the oxygen care plan and indicated that registered nurse unit managers were responsible for updating care plans. The Assistant Director of Nursing acknowledged the expectation for the oxygen to be included in the care plan.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #334 care plan was updated to include resident’s use of oxygen and a nebulizer. 2. All current resident medication administration records will be reviewed for orders for oxygen and/or nebulizer treatments and their care plans were reviewed to ensure comprehensive care plans are in place. New admissions with oxygen orders will have their care plan reviewed as described in #4 below. 3. All Registered Nurses will be re-educated on the requirement and associated time frames to develop care plans for oxygen and/or nebulizer treatments. No changes to the relevant policies were indicated. 4. All new physician orders [REDACTED]. 100% review of new orders for 3 months; no less than 75% for the next 3 months; frequency to be re-evaluated at 6 months by Quality Assurance & Performance Improvement Committee based on audit results (actual threshold of compliance will influence the decision to continue audits beyond 6 months). Responsible Party: Director of Nursing