Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for three residents, leading to discrepancies between the care plans and the current physician orders. For Resident 1, the care plan included an intervention of intramuscular Ativan for seizure activity, initiated in July 2024. However, the physician orders did not include Ativan, as it had been discontinued in May 2024. This discrepancy was confirmed during an interview with the Nursing Home Administrator (NHA), who acknowledged that the care plan should have been updated at the time of discontinuation. Resident 11's care plan was not updated to reflect the current physician orders for a consistent, controlled carbohydrate, liberal renal diet with dysphagia advanced texture and thin consistency. The care plan had not been revised since June 2023, despite changes in dietary orders. Similarly, Resident 60's care plan inaccurately indicated a therapeutic altered diet related to diabetes, while the current physician orders specified a regular diet with regular texture and thin consistency. The NHA confirmed that Resident 60's care plan was incorrect and should have been updated to reflect the current diet.
Plan Of Correction
1. Residents 1, 11, and 60 had their care plans revised. 2. An initial audit of residents who had antianxiety medications discontinued in the past 30 days was completed to ensure accuracy, as well as an initial audit of residents who have had diet changes in the past 30 days has been conducted to ensure accuracy. 3. Education was completed with nursing staff and the IDT on ensuring that care plans are updated timely with any revision. 4. Five audits of residents with discontinued antianxiety medications and five audits of residents with diet changes will be conducted weekly for 4 weeks, then monthly for 2 months by the DON or designee. Results of these audits will be presented to the QAA committee. 5. The facility will be in substantial compliance by 1/7/25.