Failure to Involve Resident in Care Planning and Update Care Plan for Medical Equipment
Penalty
Summary
The facility failed to ensure a resident's right to participate in the care planning process and did not review and revise another resident's care plan as required. Resident 19, who has chronic pain, hypertension, and muscle wasting, was not aware of her care plan meetings. Despite a scheduled meeting and attempts to contact her family, there was no documentation indicating that Resident 19 was invited to participate in her care plan meetings since August 2024. Interviews with staff revealed uncertainty about why the resident was not involved, and the Nursing Home Administrator expected residents to be invited to their care plan meetings. Resident 50, diagnosed with hemiplegia and hemiparesis following a stroke, had a physician's order for Prevalon boots to prevent bedsores, but this was not included in the care plan. Observations showed the boots were present in the resident's room, but staff were unaware of the order, leading to a lack of implementation. The Director of Nursing acknowledged the oversight and confirmed that the care plan should have been updated to include the boots, which were not properly documented or communicated to the staff.
Plan Of Correction
1. Resident 50's care plan has been updated to reflect that Prevalon Boots should be on when in bed. Resident 19's care plan meeting has been rescheduled and she has been invited to it. 2. A comprehensive review of current residents' orders will be completed by the Director of Nursing/Designee to ensure order for Prevalon boots is reflected on the care plan. A comprehensive review of current residents will be reviewed by the Social Services Director to ensure quarterly care plan meetings have been scheduled and that residents were invited to attend. 3. The facility will take the further steps to validate the problem does not reoccur by re-educating the Unit Managers/RN Supervisors and Social Services on FTAG 657 Care plan timing and revision with focus on Care plan meetings and preventative skin care measures. 4. Compliance will be monitored by the Director of Nursing/Designee, using the Care Plan Audit through a review of four residents weekly x 2 weeks and monthly x 2 to ensure accuracy of the resident's comprehensive plan of care and resident participation in care plan meetings. Results will be reported to the QAA committee and the QAA committee will determine the need for further audits.