Failure to Develop Person-Centered Care Plan for Resident with COPD
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with chronic obstructive pulmonary disease (COPD) and other health conditions, such as pulmonary hypertension, heart failure, and chronic kidney disease. The deficiency was identified when it was found that the resident's care plan did not address sensitivities to irritants like aerosol sprays and perfumes, which could adversely affect the resident's health. This oversight was discovered during a review of the resident's clinical records and facility policies. An incident was reported where a nurse aide wore perfume that had a suffocating effect on the resident, exacerbating her respiratory condition. The Director of Nursing (DON) acknowledged awareness of the incident and provided education to the staff member involved. However, the care plan still lacked specific interventions to prevent exposure to such irritants, despite the resident's known sensitivities and previous complaints about similar issues. The facility's policy on care planning requires that each resident's needs be addressed with specific goals and interventions, but this was not adhered to in the case of the resident with COPD. The absence of a comprehensive plan to manage the resident's exposure to irritants indicates a failure to ensure all staff were informed of the potential health impacts, as confirmed by the DON during an interview.
Plan Of Correction
R1 care plan was updated to include the resident's sensitivities to aerosol sprays and perfumes and the effects that the use of them could have on the residents health related to the diagnosis of COPD. The DON/designee audited residents with a diagnosis of COPD to ensure appropriate care plans are in place. The facility educated licensed staff on the development of person-centered plan of care for residents with COPD that addresses sensitivities to aerosol sprays, perfumes, and the effects that the use of them could have on a resident. The DON/designee will audit new admissions with a diagnosis of COPD to ensure care plans are developed that address sensitivities to aerosol sprays and perfumes. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.