Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident R7, who was admitted with diagnoses including Type 2 Diabetes Mellitus and Dementia, did not have a care plan developed for dementia care. This was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing. Similarly, Resident R28, who was observed taking smoke breaks, did not have a care plan addressing safety during smoking. The Unit Manager, Nurse Employee E14, was unaware of why a care plan for smoking was not developed. Additionally, Resident R155, who was admitted with prostate cancer and septic pulmonary embolism, was observed to be in pain without a corresponding care plan for pain management. Despite having physician orders for hospice services and pain medications, no care plan was developed to address the resident's pain related to the cancer diagnosis. This oversight was confirmed in an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged the expectation that care plans should be developed for all resident care needs.
Plan Of Correction
Care plans for R7, R28, R155 have been updated to reflect dementia, smoking, and pain management as appropriate. All residents' care plans have been reviewed and updated. Unit managers will be educated by staff development or designee on the importance of ensuring up to date and accurate care plans. Care plans will be audited by unit managers or designee monthly x 3 months then quarterly thereafter. Results will be reported in monthly QAPI.