Care Plan Updates Not Reflecting Changes in Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in residents' care needs for seven residents. For Resident 2, the care plan was not updated to reflect a change in code status from full code to Do Not Resuscitate (DNR), despite a physician's order indicating the change. The Director of Nursing confirmed that the care plan should have been updated to reflect this change. Resident 25's care plan was not revised to include Enhanced Barrier Precautions (EBP), contact, and droplet precautions, even though there was signage indicating these precautions were in place. Similarly, Resident 79's care plan was not updated to include EBP, despite signage indicating the precautions. Interviews with staff confirmed the lack of documentation in the care plans for these precautions. Other deficiencies included Resident 41's care plan not being updated to reflect the discontinuation of an antibiotic, Resident 64's care plan not reflecting a change in out-of-bed orders to an evolution chair, Resident 106's care plan not being updated to reflect hospice services, and Resident 130's care plan not reflecting the discontinuation of a diuretic. These omissions were confirmed through interviews with the Director of Nursing and other staff members.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This Plan of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #2 careplan changes were completed and are accurate. Resident #25 careplan changes were completed and are accurate. Resident #41 careplan changes were completed and are accurate. Resident #64 careplan changes were completed and are accurate. Resident #79 careplan changes were completed and are accurate. Resident #106 careplan changes were completed and are accurate. Resident #130 careplan changes were completed and are accurate. To identify other residents with the potential to be affected, the Director of Nursing/designee will review care plans to ensure any changes to code status, Enhanced Barrier Precautions, antibiotics, out of bed orders, hospice care and residents on diuretic medication within the last two weeks were reviewed/revised correctly on the care plan. To prevent a future occurrence, the Director of Nursing/designee provided education to the interdisciplinary team on the comprehensive care planning policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure any changes to orders are reflected on the care plan. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.