Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents, as required by regulatory standards. Resident 16, who had a pressure ulcer in the sacral region, did not have interventions for this condition included in their care plan, despite it being noted in the Minimum Data Set (MDS) Care Area Assessment (CAA) summary. Similarly, Resident 48, diagnosed with obstructive uropathy and having an indwelling catheter, lacked a care plan addressing this issue, even though it was identified in the MDS CAA summary. Resident 132, who was admitted with neoplasm of the bladder and pancreas, cervicalgia, and migraines, was receiving daily scheduled pain medication, yet their care plan did not address pain management as noted in the MDS CAA summary. Additionally, Resident 143, who was frequently incontinent and had diagnoses including acute cerebrovascular insufficiency, cellulitis, and psoriasis, did not have their urinary incontinence addressed in the care plan, despite it being highlighted in the MDS CAA summary. The Director of Nursing confirmed these care areas were not addressed in the care plans during an interview.
Plan Of Correction
1. Care Plans for Residents 16, 48, 132, 143 were reviewed and updated. 2. An audit of current residents' Care Plans of all residents that have sacral wound, indwelling catheter, foley, pain will be reviewed to ensure they include a comprehensive plan of care with interventions that are individualized for each resident. 3. Licensed Nursing staff will be re-educated on the importance of reviewing and updating care plans and areas identified through the Care Assessment Area are completed in the resident care plan. 4. The DON and/or designee will complete weekly random audits x 90 days on five resident Care Plans to ensure areas identified in the CAA are contained on the resident care plan. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.