Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. Resident #53, diagnosed with post-traumatic stress disorder (PTSD), did not have goals or interventions related to their PTSD in their care plan. Despite the resident's moderate cognitive impairment and expressed need for mental health services, the care plan lacked specific behavioral symptoms to monitor or interventions to manage the PTSD. Interviews with staff revealed a lack of awareness and documentation regarding the resident's PTSD, which resulted in inadequate care planning. Resident #220, who required care for a nephrostomy tube due to acute kidney failure and other conditions, did not have any related goals or interventions in their care plan. The resident reported not receiving any teaching about nephrostomy tube care, and documentation showed inconsistent flushing of the tube as ordered by the physician. Staff interviews confirmed that the care plan should have included nephrostomy tube care, but it was not addressed, indicating a gap in the resident's care planning. Resident #104, with a history of stroke and hemiparesis, had a physician's order for compression wraps to manage swelling in the left arm. However, observations revealed that the compression wraps were not applied as documented, and the care plan did not include this intervention. Interviews with nursing staff highlighted discrepancies in treatment documentation and a failure to communicate and apply the necessary treatment, resulting in unmet care needs for the resident.
Plan Of Correction
Plan of Correction: Approved February 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #53’s care plan was updated to include goals and interventions related to the resident’s post-traumatic stress disorder diagnosis. Resident #220’s care plan was updated to include goals and interventions related to care of the resident’s nephrostomy tube. Resident #104 had their ACE wraps applied. Nurses on those shifts will be counseled. 2. A full house audit of the comprehensive care plans was completed, and care plans were updated with specific focus related to their [DIAGNOSES REDACTED]. 3. Policy named Care Plan-Comprehensive was reviewed and no changes were made. IDT and licensed nursing staff will be educated by the Regional consultant on care plan development, revision, review, and conducting of care plan meetings. The interdisciplinary clinical team will review changes in resident’s condition and revise care plan upon admission, readmission, and changes in resident’s condition, quarterly and annually. Care plan development or revision will occur in clinical meetings by the Interdisciplinary Team. Changes in resident’s care plan will be updated by the unit manager or responsible discipline. 4. The Unit manager or designee will audit all new admissions for completeness of the comprehensive care plan weekly for a duration of 3 months. A random audit of 5 resident comprehensive care plans per week x 12 weeks will be conducted by IDT Team and then 5 random resident comprehensive care plans on an ongoing basis per quarter. DON will provide onsite oversight of the IDT care plan meetings and provide feedback to the Regional Director on the effectiveness of the interventions. The Director of Nursing will report audit findings to the QAPI committee for review and recommendation on continuance of monitoring.