Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were updated or revised to reflect their specific care needs. For Resident 46, the care plan was not updated to indicate that the active range of motion restorative nursing program for her bilateral lower extremities was stopped after a decline in her lower extremity strength and mobility. This was confirmed by the Director of Nursing during an interview. Resident 54's care plan was not revised to reflect the discontinuation of her anti-anxiety medication, despite the Medication Administration Record and physician's orders indicating that the medication was no longer prescribed. The Director of Nursing confirmed this oversight during an interview. Similarly, Resident 65's care plan was not updated to reflect the placement of a catheter, which rendered the existing care plan regarding bladder incontinence inapplicable. For Resident 73, the care plan was not updated to reflect that the resident only had a med port and did not require staff to check for a bruit and thrill, as there was no other dialysis access site. This was confirmed by a Licensed Practical Nurse and the Director of Nursing. Additionally, Resident 77's care plan was not revised to reflect her current transfer status, which required only one assist with a front-wheeled walker, as per the physician's orders. This discrepancy was also confirmed by the Director of Nursing.
Plan Of Correction
1. The plan of care for R46, R54, R65, R73, and R77 will be reviewed and corrected. 2. The Director of Nursing or designee will audit the last comprehensive care plan completed for all current residents. The comprehensive care plan will be updated with all issues identified. 3. The Director of Nursing or designee will re-educate the interdisciplinary team on the comprehensive care plan requirements for completion and accuracy in accordance with the Resident Assessment Instrument, RAI, manual and federal regulation. 4. The Director of Nursing or designee will audit all newly completed comprehensive care plans for accuracy. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.