Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. For Resident 79, the care plan did not include interventions to minimize anxiety and aggression by attempting care with one staff member or offering diet soda as suggested by the resident's daughter. Despite documentation indicating these suggestions, the care plan was not updated, and staff continued to provide care with two staff members without offering the diet soda. Resident 81's care plan was not developed to address dental health concerns despite multiple indications of dental issues, including tooth pain and decaying teeth. The facility's consultant dentist had documented these issues, but the registered nurse assessment coordinator did not review the dental progress notes when completing the MDS assessment, resulting in an inaccurate assessment that did not trigger a dental care plan. Resident 86's care plan was not revised to reflect the loss of her partial dentures, which had been missing for eight months to a year. Although the facility's consultant dental provider had assessed Resident 86 for new dentures, the care plan still indicated that she had partial dentures, failing to address her current needs. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed these deficiencies in care plan revisions.
Plan Of Correction
1. Resident 79's care plan was updated to include attempt care with 1 staff member and their tasks updated to include providing a diet coke. Resident 81's care plan was updated with a dental plan of care. Resident 86's care plan was updated with her current dental status. Resident 81's care plan was updated to include a dental plan. Resident 86's care plan was updated with her current dental status. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary. 2. Care conferences and consultant dental visit notes from the last 30 days were reviewed by RNAC/designee to verify any interventions/changes that were noted were added to the resident's care plan. 3. DON or designee will re-educate IDT and licensed staff on care planning and consultant dental visit interventions/changes. 4. DON or designee will complete random audits of care plan meetings and consultant dental visit notes to verify interventions/changes are discussed are added to the resident's care plan and captured on the MDS weekly X 4 then monthly X 3. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.