Failure to Implement Baseline Care Plan for Resident's Immediate Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission for a resident, which included the necessary healthcare information to address the resident's immediate needs. The resident was admitted with diagnoses including spinal stenosis, atherosclerotic heart disease, and type 2 diabetes. The Admission Minimum Data Set (MDS) indicated the resident had an intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and a moderate depression score of 10 on the Resident Mood Interview. However, no BCP was initiated to address the resident's mood. The Director of Social Services (DSS) acknowledged the responsibility to assess the mood section of the MDS and stated that a referral for psychological services was made, but could not provide documentation of the referral or services provided. The DSS admitted that a mood care plan should have been initiated due to the high mood score. The facility's policy required a baseline care plan to be developed within 48 hours of admission, including therapy and social services, but this was not done for the resident in question.
Plan Of Correction
1/24/25 1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. 1) Resident #1 NU Ex Order 26.4(b)(1) at the facility. On 1/22/2024 the Assistant Director of Nursing /FE (ADON/FE) completed an audit of all new admissions in the last 30 days to ensure a baseline care plan was initiated within 48 hours of admission and included person-centered care planning. There were no untoward findings. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. 2) All residents have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. 3) On 12/27/2024 the Assistant Director of Nursing/Facility Educator (ADON/FE) immediately provided in-service education to all nurses including shift supervisors and unit managers on the procedure for developing a baseline care plan within 48 hours of admission. The baseline care plan must include the minimum healthcare information necessary to properly care for a resident including, but not limited to a) initial goals based on the physician orders; b) physicians orders; c) dietary orders; d) therapy orders; e) social services; f) PASARR recommendation, if applicable. On 1/22/2025 The ADON/FE provided in-service education to the [R] and U.S. FOIA (b) (6) regarding the process of developing a baseline care plan within 48 hours of admission. The baseline care plan must include the minimum healthcare information necessary to properly care for a resident. The Unit Manager or designee will review all new admission records daily to ensure a baseline care plan has been initiated within 48 hours of admission. This review will continue on an ongoing basis. On 1/22/2025 the ADON/FE provided in-service education to the [R] the [R] and U.S. FOIA (b) (6) on the importance of a personalized care plan for depression as well as psychology consult for any resident with a PHQ9 over the score of 10, which notes signs and symptoms of depression. The Director of Social Services and ADON/FE have created a formal record for tracking all referrals made to a psychologist. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. 4) The Director of Nursing or designee will conduct audits of 100% of newly admitted residents to ensure a baseline care plan has been implemented within 48 hours of admission. The audits will continue daily on an ongoing basis to ensure compliance. The results of the audits will be reported to the Administrator and the Quality Assurance Performance Improvement (QAPI) Committee monthly x 3 months, then quarterly x 3 quarters. The Director of Social Services or designee will conduct audits of all residents who have referrals for psychology consults. The audits will be conducted weekly x 3 weeks, then monthly x 3 months, then quarterly x 3 quarters. The results of the audits will be provided to the Administrator and QAPI Committee monthly x 3 months then quarterly x 3 quarters. The QAPI Committee will review and determine need for further audits. The QAPI Committee meets on a monthly basis.