Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for five out of fourteen residents, as required by the Resident Assessment Instrument (RAI) User's Manual and the facility's own Comprehensive Care Planning Policy. The RAI User's Manual mandates that for each triggered Care Area, a decision must be made within seven days regarding whether a new care plan, revision, or continuation is necessary. However, for residents R22, R32, R44, R150, and R195, the Section V Care Area Assessment (CAA) Summary, Question V0200, was not completed, indicating a lack of proper assessment and care planning. Each of these residents had significant medical conditions, including diabetes mellitus, chronic kidney disease, end-stage renal disease, heart failure, dementia, and lung cancer. Despite these diagnoses, their care plans dated January 9, 2025, did not include goals and interventions related to diabetes mellitus, a critical aspect of their care needs. The Nursing Home Administrator and Director of Nursing confirmed the facility's failure to develop and implement comprehensive care plans to meet the residents' needs, as required by 28 Pa. Code 211.11(d).
Plan Of Correction
Residents 22, 32, 44, 150, and 195's care plans were reviewed and care plans were updated to reflect diabetes by the RNAC/ designee. Current residents with diabetes have the potential to be affected. A comprehensive audit of current residents with diabetes was completed by the RNAC/ designee to ensure diabetes is reflected in the care plan. Corrections were made as needed. To prevent recurrence, the IDT will be educated on the Comprehensive Care Plan policy by the NHA/ designee. To maintain and monitor compliance, the DON/ designee will audit 5 residents with a diabetes diagnosis weekly x 4 weeks and monthly x 2 months to ensure diabetes is reflected in the care plan. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.