Failure to Implement Comprehensive Care Plan for Resident's Wheelchair Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with Alzheimer's Disease, who had a physician's order for a wheelchair with bilateral leg rests. Despite the order, the resident was repeatedly observed sitting in a wheelchair without the required leg rests, with their feet resting on the floor. This was noted during multiple observations over several days, and staff interviews revealed that the leg rests were not available in the resident's room or the spare supply area. The facility's policy mandates that residents must not be transported without foot pedals, yet this was not adhered to in the case of the resident. Staff interviews indicated a lack of communication and responsibility regarding the missing leg rests. A Certified Nursing Assistant, not regularly assigned to the resident's unit, attempted to locate the leg rests but was unsuccessful. The Rehabilitation Department Director confirmed the necessity of leg rests for the resident, and a Licensed Practical Nurse acknowledged the oversight and stated a work order was placed with the maintenance department to address the issue. The Director of Nursing Services later stated that the staff should have contacted the Maintenance and Rehabilitation department immediately upon noticing the absence of leg rests, rather than directing a CNA to search for spare parts.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample: Resident #152 On 12/5/24 Rehabilitation staff checked the resident’s wheelchair to ensure that the leg rests placed by the maintenance staff were appropriate for the resident and were consistent with the resident’s care plan for use of elevating leg rests as per physician order [REDACTED]. The IDCP Team reviewed the overall CCP to ensure that it was person-centered, and no issues were identified. The Nurse Manager reviewed the plan of care with the unit staff to ensure that staff understood the importance of adhering to the facility policy for Wheelchair Safety, physician orders [REDACTED]. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents who require the use of a wheelchair with leg rests have been identified as potentially being affected by the same practice. The Nurse Managers and Rehabilitation staff will identify all residents who require a wheelchair with leg rests. The IDCP Team will review the plan of care for all identified residents to ensure that an order for [REDACTED]. The IDT will continue to review and revise each resident’s CCP on a quarterly and as needed basis to ensure that the CCP is person-centered for the individual resident. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Chief Nursing Officer and MDS Coordinator reviewed the policy and procedure for Comprehensive Care Plans, including protocols related to person-centered care plans and staff following the plan of care for individual resident needs, such as providing leg rests to residents who require the use of a wheelchair and leg rests, and determined that the policy is consistent with the facility’s practices. The Staff Educator/designee will provide education to the IDCP Team regarding care planning protocols and the facility’s policy. Education will address the importance of adhering to the plan of care related to person-centered interventions, such as providing a wheelchair with leg rests as ordered. This education will be incorporated into the orientation of new IDCP Team members and will be reviewed on an as needed basis. The Nurse Managers/designee will monitor compliance with the comprehensive care plan policy during review of the comprehensive care plan at care plan meeting discussions and during audits of staff following the person-centered care plan interventions. Immediate corrective actions, such as revision/updating of an individual resident’s care plan or staff re-education regarding following the person-centered interventions, will be implemented, as needed. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The Chief Nursing Officer and MDS Coordinator will develop an audit tool to monitor compliance with the requirements of F-656 including person-centered care plan interventions and staff adherence to following the plan of care. The MDS Coordinator/designee will audit 20% of resident CCPs monthly for the next three months and then quarterly for an additional two quarters. Residents requiring a wheelchair with leg rests will be included in the audit sample. All care plan audit findings will be reported to the Administrator and CNO. Corrective action, such as staff re-education regarding following the plan of care or revision/updating of a resident’s CCP, will be implemented as indicated. The MDS Coordinator will report all comprehensive care plan audit findings to the QAPI Committee monthly for three months and then quarterly for an additional two quarters for evaluation and discussion. The accepted level of compliance is 95%. At the end of the 3rd quarter a decision will be made by the QAPI Committee regarding the need for ongoing monitoring specific to comprehensive care planning and at what frequency. Completion Date: 01/31/2025 Responsibility: MDS Coordinator