Failure to Develop Timely Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop a person-centered baseline care plan within 48 hours of admission for several residents, leading to deficiencies in addressing their immediate needs. Resident R158, who primarily speaks Vietnamese, did not have a care plan reflecting language barrier services or specific activity programs based on her preferences. Despite the resident's limited English proficiency, the care plan did not include the necessary LEP services, and staff relied on anticipating her needs without frequent use of interpreter services. Resident R315, who was admitted with multiple fractures and a surgically wired jaw, had a care plan that failed to include emergency procedures for removing the jaw wires. Although pliers were available at the bedside for emergencies, this critical intervention was not documented in the care plan. This oversight could potentially delay emergency response in case of aspiration risk, which was noted in the care plan. Resident R417, who communicated primarily in Vietnamese and had moderate cognitive impairment, did not have a care plan addressing communication needs despite triggering a review in the Care Area Assessment. Additionally, Resident R420, admitted with suicidal ideations and bipolar disorder, lacked a care plan addressing his specific mental health needs. These omissions were confirmed by interviews with the Nursing Home Administrator and the Director of Nursing, highlighting a failure to develop appropriate baseline care plans for residents with specific language and mental health needs.
Plan Of Correction
This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. Residents' R417 and R158 Baseline care plans were updated to reflect a different language spoken other than English. An audit was completed for all residents that communicate in a language other than English to ensure that their baseline care plans are complete. Nursing staff will be educated to ensure that baseline care plans are initiated within 48 hours of admission. DON/Designee will audit all new admissions to make sure that residents that do not communicate with English being their primary language have a baseline care plan established. Audits will be done weekly x4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed. Wired jaw - Resident's R315 baseline care plan was updated to include removing the wires from the jaw in an emergency. No other residents were affected. Nursing staff will be educated to ensure that baseline care plans for any residents with a wired jaw are developed within 48hrs of admission to the facility. DON/Designee will audit all new admissions to make sure that residents with a wired jaw have a plan of care developed to include removing the wires from the jaw in an emergency. Audits will be done weekly x4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed. Bipolar and suicidal ideation - Resident R420's care plan was developed to reflect his specific health needs related to suicidal ideation and bipolar disorder. An audit of all residents with a diagnosis of Bipolar Disorder and suicidal ideation was completed to ensure that they had care plans developed related to mental health needs related to suicidal ideation and bipolar disorder. Nursing staff will be educated to ensure that care plans are developed for all residents with bipolar disorder and suicidal ideations. DON/Designee will audit all new admissions to make sure that residents that have a diagnosis of bipolar disorder or suicidal ideation have a care plan developed. Audits will be done weekly x4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed.