Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that residents' comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment and as needed. This deficiency was identified during a recertification survey, affecting two residents. Resident #35, who has a history of smoking, had a care plan related to smoking that was not reviewed and revised quarterly after each assessment. Despite the facility's policy requiring quarterly updates, there was no documented evidence of review or revision for several quarters. Interviews with staff, including a Registered Nurse, the Recreation Director, and the Director of Nursing, revealed a lack of clarity and responsibility regarding the updating of care plans. Resident #18, who was admitted with a history of falls and required assistance for most activities of daily living, experienced a fall in the facility. Despite this incident, there was no documented evidence that the resident's care plan was reviewed and revised following the fall. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that the fall should have been documented and the care plan updated. The Minimum Data Set Coordinator also indicated that Registered Nurse Managers are responsible for initiating and updating care plans, but there was a failure to ensure this process was followed.
Plan Of Correction
Plan of Correction: Approved January 30, 2025 Element 1 - Resident #35 care plan was reviewed by DNS; all appropriate care plans reviewed and revised as needed. - Resident #18 care plan was reviewed by DNS; all appropriate care plans reviewed and revised as needed. - An audit was completed on all residents with smoking care plans to ensure they were reviewed and revised as needed. - An audit was completed on all residents with recent falls within the last 30 days to ensure fall care plan was reviewed and revised as needed. Element 2 All residents had potential to be affected by the deficient practice. Element 3 - The facility's policy titled Care Plans Comprehensive was reviewed; no revisions at this time. - In-service to all Registered Nurses and Licensed Practical Nurses on resident care plan timing and revision process is ongoing. - Audit tools in place to ensure smoking and fall care plans are reviewed and revised as needed, minimum quarterly for all residents. Bi-weekly for 2 weeks, monthly for 3 months. Element 4 - Audit tools in place to ensure care plans are reviewed and revised as needed, minimum quarterly for all residents. - Any deficient findings will be addressed immediately. - All audit findings will be reported to QAPI committee monthly for 3 months. Responsible Party: DNS/Designee