Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which led to deficiencies in addressing their specific medical needs. Resident 62, who was cognitively intact and required assistance for daily care, was diagnosed with Parkinson's disease and vascular dementia. Despite having physician's orders for medications to manage these conditions, there was no evidence of a care plan to address the care and treatment needs associated with his Parkinson's disease or dementia. Similarly, Resident 68, who was also cognitively intact and required assistance for daily care, was diagnosed with PTSD and had identified triggers. However, as of the survey date, there was no care plan developed to identify or address the resident's PTSD or his triggers. The Director of Nursing confirmed the absence of these care plans, acknowledging that they should have been developed.
Plan Of Correction
1. Resident 62 was discharged. The care plan for Resident 68 was updated. 2. The facility's Registered Nurse Assessment Coordinator and Social Worker, or designees, will audit the care plans of the in-house residents with diagnoses of post-traumatic stress disorder, dementia and Parkinson's Disease to assure they address these conditions. 3. The members of the Interdisciplinary Team involved in care planning will be re-trained on the care planning process by the Regional Clinical Reimbursement Specialist or a designee. 4. The Director of Nursing, or a designee, will conduct audits of five random residents' care plans related to the above diagnoses twice weekly times two, weekly times two and monthly times two. 5. The audit results will be reviewed in the monthly quality assurance meetings to address any identified issues promptly.