Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to reflect the specific care needs of three residents. For one resident, the care plan inaccurately indicated the use of antidepressant and antianxiety medications, which were not being administered according to the Medication Administration Record (MAR). The Director of Nursing confirmed that the resident should not have had a care plan for these medications. Another resident's care plan was not updated to reflect changes in transfer status and shower preferences, and it incorrectly included a plan for antipsychotic medication, which was not being administered. The Director of Nursing acknowledged these discrepancies. Additionally, a third resident's care plan was not updated when wound vac treatment was discontinued, despite new wound care orders being documented in the nurse's notes. The Director of Nursing confirmed that the care plan should have been updated to reflect the discontinuation of the wound vac. These deficiencies indicate a failure to maintain accurate and current care plans for residents, as required by facility policy and regulatory standards.
Plan Of Correction
1. The care plans for the in-house cited residents were updated. 2. The facility's Interdisciplinary Team staff responsible for care planning will audit the care plans of the in-house residents against the residents' current physician order sets. The care plans will be updated accordingly. 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 order changes 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.