Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the care plans for two residents, resulting in deficiencies in accurately reflecting their current status and care needs. Resident R8, who was admitted with diagnoses of heart failure, mild cognitive impairment, and anxiety disorder, had a physician order for the use of a FreeStyle Libre 3 Continuous Glucose Monitoring system. However, the care plan did not include the use, care, and service interventions related to this device. This omission was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident R316, who was admitted with high blood pressure, Multiple Sclerosis, and diabetes, had a physician order for a Wound Vac to be applied to a sacral wound. The care plan for this resident also failed to include the necessary interventions for the Wound Vac, as confirmed by the DON. These deficiencies indicate that the facility did not update the care plans to reflect the residents' current medical needs and interventions as required by their policy and state regulations.
Plan Of Correction
The care plans of the affected residents (R8 and R316) were updated during survey to include the continuous glucose monitoring device and the wound vac. All the care plans of residents having either a continuous glucose monitoring device and/or a wound vac were reviewed and/or updated to ensure compliance. RNs, and LPNs, will be educated by the Director of Nursing, In-Service Director and/or designee that care plans should be created and/or updated timely to reflect the current condition of the resident including their use of a continuous glucose monitoring device and/or a wound vac. The facility will audit the care plans of all residents with continuous blood glucose monitoring devices and/or wound vacs weekly for three weeks and then biweekly for three weeks to ensure that the care plans reflect the current needs of the residents utilizing these devices. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.