Incomplete Transfer of Resident Care Plans During EMR System Change
Penalty
Summary
The facility failed to maintain accurate clinical records for one of the 18 residents sampled, specifically Resident 19. Resident 19 was admitted with a diagnosis of acute dementia, including Dementia with Lewy Bodies, which affects mental abilities and can cause visual hallucinations. The facility transitioned to a new electronic medical record system on April 8, 2024, but did not completely transfer all care plans, including the dementia care plan for Resident 19. During an interview, the Director of Nursing confirmed that Resident 19's care plan was incomplete and acknowledged that not all resident medical information was transferred to the new system. The Director of Nursing was unaware of how many current residents had complete medical records at the time of the survey.
Plan Of Correction
Resident 18 is deceased and resident 19 dementia care plan has been added. To identify other residents with the potential to be affected, the DON/designee completed an audit of all residents with dementia diagnosis to ensure care plan was developed and met residents individualized needs and care. To prevent this from re-occurring, the DON/designee educated the licensed nursing staff on dementia, specific individualized needs and plan of care. To monitor and maintain ongoing compliance, the DON/designee will audit new admissions with a diagnosis of dementia to confirm all care plans meet resident's individualized needs and care weekly then monthly x 2. All results will be brought to QAPI committee.