Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in addressing their medical needs. For Resident 22, the clinical records indicated that the resident was experiencing urinary retention and had a foley catheter inserted as per the CRNP's orders. Despite these medical interventions, the facility did not create a care plan to address the urinary retention or the use of the foley catheter. This oversight was confirmed during an interview with the Nursing Home Administrator and Director of Nursing. Similarly, Resident 108's care plan was found lacking in addressing changes in their medical treatment. The resident, who was being treated for congestive heart failure, had an increase in their Lasix dosage due to persistent edema in the right elbow. However, the facility did not update the care plan to reflect the increase in Lasix or the presence of right elbow edema. This deficiency was confirmed by the Director of Nursing during an interview.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1. Facility failed to develop a comprehensive care plan for R22 for urinary retention with placement of a foley catheter and R108 for increase in Lasix and right elbow edema. Care plans were updated for both residents. 2. Audit of current residents completed to ensure that changes were added to care plans. 3. DON/Designee will complete education to licensed staff on the components of this regulation to include the need for comprehensive care plans for changes. 4. DON/Designee will complete audits of 5 residents 2 x a week x 4 weeks, then 1 x a week x 4 weeks, then 2 x a month, then 1 x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/ Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings in QAPI. 5. Date of compliance will be 2/28/2025.