Failure to Develop Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop baseline care plans for two residents, leading to deficiencies in their care. Resident R114, who was admitted with orthopedic aftercare needs, expressed dissatisfaction with her bathing arrangements, as she was only provided with a basin of water and had not had her hair washed since admission. Her care plan did not include interventions related to her preferences and assistance needs for bathing, and a nurse aide was unable to state the level of assistance or preferences required by the resident. Resident R277, admitted with a surgical abdominal wound requiring dressing changes, did not have a care plan indicating the need for enhanced barrier precautions, despite a sign outside her door stating such precautions were necessary. A licensed nurse confirmed the requirement for enhanced barrier precautions due to the resident's surgical wound, but there were no physician orders or care plan documentation to support this need.
Plan Of Correction
1. R114 was given a shower at the time of request. R277 no longer resides in the center. 2. An initial audit was conducted of current residents to validate care plans are updated with bathing preferences and assistance needs. An initial audit was completed of residents that require enhanced barrier precautions to validate orders and care plans. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. DON/Designee educated the nursing staff on residents' bathing preferences and assistance needs and obtaining orders and updating care plans for enhanced barrier precautions. 4. DON/Designee will conduct a random audit to ensure shower preferences are being met and enhanced barrier precautions orders and care plans are updated. This audit will be conducted 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.