Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, addressing their medical, physical, mental, and psychosocial needs. Resident 10, diagnosed with major depressive disorder and hypertension, was identified as a smoker who required supervision. However, her care plan did not include a smoking care plan until it was added on December 4, 2024, after the deficiency was noted. Similarly, Resident 60, who was admitted with major depressive disorder and dementia, did not have a dementia care plan in place upon admission, which was only added on December 4, 2024. Resident 75, diagnosed with urinary retention and cancer, was also identified as a smoker. Despite having multiple smoking evaluations indicating their smoking status, their care plan did not reflect their desire to smoke until it was updated on December 4, 2024. These omissions in the care plans were confirmed by the Nursing Home Administrator, who acknowledged that the care plans should have included these focus areas prior to the survey findings.
Plan Of Correction
1. Residents 10, 60, and 75 had their care plans corrected to reflect smoking and dementia diagnosis. 2. An initial audit of residents who smoke and residents with dementia diagnosis was completed to ensure that their care plans reflect these items. 3. Education was completed with nursing staff, therapy staff, and IDT on ensuring that care plans are developed for residents who smoke and residents that have dementia diagnosis. 4. 5 audits of residents who smoke and 5 residents with dementia diagnosis will be conducted weekly x 4, then monthly x 2 by DON or designee. Results of these audits will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.