Failure to Revise Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team after each assessment, as required by their policy. This deficiency was identified during a recertification and abbreviated survey, specifically affecting a resident who was reviewed for dental care. The resident, who had diagnoses including Anxiety Disorder, Dysphagia, and Type 2 Diabetes Mellitus, had a care plan for oral/dental care that was created on August 11, 2023. However, there was no documented evidence that this care plan had been reviewed or revised following the quarterly assessments conducted on April 18, 2024, July 10, 2024, and October 2, 2024. The facility's policy mandates that care plans be reviewed at intervals not exceeding 92 days after the last assessment reference date. Despite this requirement, the care plan for the resident's oral/dental care was not updated as necessary. During an interview, the Director of Nursing acknowledged the oversight, stating that while they strive to review and revise care plans, it sometimes does not get done. The responsibility for developing and updating care plans was attributed to the Minimum Data Set Coordinator and the Registered Nurse supervisors, but no interview with the MDS Coordinator was conducted to further explore the issue.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 Immediate Correction 1) On 12/30/24, Resident #17 was assessed by MD. 2) Dental Consult was done on 12/19/24 at the hospital. 3) On 12/10/24, The comprehensive care plan for Resident #17 related to oral/dental care was reviewed and revised by the interdisciplinary team (IDT) to reflect the current assessment and oral health status. 4) The care plan now includes measurable goals, updated interventions, and a schedule for follow-up evaluations. 5) On 12/30/24, The Minimum Data Set (MDS) Coordinator and the registered nurse supervisor responsible for Resident #17’s care plan were counseled and re-educated on care plan timing and revision requirements. Identification of Others 1) A facility-wide audit in the last 30 days will be conducted to identify residents whose care plans had not been reviewed or revised within the required timeframes. 2) Care plans for all residents identified in the audit will be reviewed and revised as needed. Systemic Changes 1) The facility's policy on Comprehensive Care Planning was reviewed and revised by the Facility Administrator to explicitly include: - Care plan reviews and updates must occur after every comprehensive and quarterly assessment. - A checklist for MDS Coordinators and the IDT to ensure compliance with the 92-day review requirement. - Documentation requirements for resident and/or representative participation in care plan meetings or reasons for their absence. 2) MDS Coordinator, RN's and LPN's were re-educated on care plan timing and revision regulations by the Director of Nursing (DON). 3) Training emphasized the importance of timely care plan updates, interdisciplinary collaboration, and accurate documentation. 4) IDT meetings were restructured to include a dedicated review of residents due for care plan updates within the next 30 days. 5) The MDS Coordinator will send reminders to IDT members seven days prior to quarterly care plan review deadlines. 6) A care plan audit tool was developed and implemented to ensure that all care plans are reviewed, revised, and updated as required. 7) The tool will track care plan creation, review dates, and changes made during assessments. Quality Assurance (QA) 1) The DON or designee will complete random care plan audits quarterly for one year to monitor ongoing compliance. 2) Resident council meetings will include a discussion on care plan updates to ensure resident participation and satisfaction with their care plans. 3) Audits will be completed by the Director of Nursing weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Director of Nursing.