Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the care plans for four residents, leading to deficiencies in their care. Resident 2, who was dependent on a ventilator and had a history of falls, had an outdated care plan that did not reflect the intervention for bilateral fall mats after an unwitnessed fall. The RNAC acknowledged that the physician's order was not updated, which prevented the care plan from being revised accordingly. The DON confirmed that the care plan should have been updated with the fall intervention. Resident 26's care plan was not updated to reflect the discontinuation of Amphetamine-Dextroamphetamine, and the care plan for anti-anxiety medications lacked detailed interventions and monitoring guidelines. The care plan for anti-psychotic medication was also not individualized. The DON and Nursing Home Administrator both recognized that the care plan should have been revised during the care plan meeting. Resident 29's care plan did not initially include the use of bilateral thick fall mats, despite having an order for them and their presence since admission. The care plan was only updated after the surveyor's observation. Resident 37's care plan still included a resolved blister wound, which had not been revised since March 2024. The DON acknowledged that the care plan should have been updated to reflect the resolution of the wound.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R2, R26, R29, R37. 2) The Facility updated R2, R26, R29, R37 care plans to reflect current resident orders and plan of care. 3) All resident care plans were reviewed to ensure that care plans to reflect current resident orders and plan of care. Two: system changes and measures that will be taken: 1) All Licensed and IDC staff will be in-serviced on initiating, updating and resolving care plan items. 2) Care plans will be monitored at Daily Clinical meetings and updated as necessary. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 (5) random residents 3x week for 4 weeks for compliance with careplans, then five (5) random residents 1x week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.