Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident R46, who was diagnosed with physical aggression, paranoia, insomnia, and was taking antipsychotic medication for psychosis. Despite being alert and oriented, Resident R46 was involved in multiple altercations, including a verbal altercation on May 2, 2024, and a physical altercation on October 12, 2024, which resulted in injuries to another resident. The facility's documentation did not include a care plan addressing these behaviors or the resident's insomnia and medication needs. Additionally, the facility did not create a care plan for Resident R170, who required oxygen therapy. Resident R170 was admitted with diagnoses of anemia and acute myeloblastic leukemia and had a physician's order for oxygen use as needed for shortness of breath. However, there was no care plan developed to address the resident's respiratory needs or the use of oxygen, as confirmed by the Assistant Director of Nursing. These deficiencies indicate a failure to adhere to the facility's policy of developing comprehensive, person-centered care plans that address the medical, nursing, and psychosocial needs of residents. The lack of care plans for both residents R46 and R170 highlights a significant oversight in ensuring the well-being and safety of residents, as required by regulatory standards.
Plan Of Correction
1. On 12/18/2024 the nurse management team developed a care plan for Resident R46 addressing physical aggression, paranoia, suspicious behaviors and insomnia. Resident R170 is no longer in the facility. 2. On 12/26/2024 the nurse management team reviewed the Electronic Health Record of residents with a history of physical or verbal aggression, paranoia and suspicious behaviors. Care plans for those residents were reviewed and revised as needed. 3. During the morning clinical meeting the Interdisciplinary Team will review all admissions and notes from the most recent psych visit to develop a comprehensive care plan that includes resident specific behaviors including physical aggression, paranoia, suspicious behaviors and insomnia. 4. Education on the development of comprehensive care plans to address resident specific behaviors including physical aggression, paranoia, suspicious behaviors and insomnia will be presented by the DON/designee to nursing staff and the Interdisciplinary Team members by 01/16/2025. 5. Audits of comprehensive care plans that include resident specific behaviors for residents physical or verbal aggression, paranoia and suspicious behaviors will be completed weekly for 1 month and then monthly for 1 quarter. Audits will be forwarded to the monthly Quality Assurance Performance Improvement Meeting and evaluated by the Quality Assurance Committee.