Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as Resident R1, who was admitted with diagnoses including unspecified dementia, hypertension, and renal insufficiency. The deficiency was identified through a review of facility documentation, clinical records, and staff interviews. The facility's policy requires staff to document all care and services provided, including identification, evaluation, intervention, and attempts to revise the care plan to address changing needs. However, the review revealed that there was no care plan specifically addressing the resident's high blood pressure, despite it being a significant medical condition. Additionally, the facility did not follow the existing care plan for Resident R1's identified adverse behaviors, which included resisting care. The medication administration record showed inconsistencies in the application of a prescribed Clonidine patch, with some entries left blank and no documentation of the resident's refusal or staff's attempts to address the refusal. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of a care plan for high blood pressure and acknowledged the failure to follow the care plan for behavioral issues related to medication refusal.
Plan Of Correction
Resident R1's care plan was immediately updated upon return from hospital. All like residents, with Hypertension and Dementia, that interferes with daily living, will have care plan(s) and orders to prevent or lessen the risk of negative outcomes as it relates to the diagnoses and adverse behaviors. All staff will receive education on policy N-A-01 All Policy and Procedures: General Guidelines, N-A-40 Assessment-MDS/RAI and Care Planning and N-A-44 Assessment-Comprehensive Person-Centered Care Planning. DON/ADON/Designee to audit all current care plans to ensure proper interventions for all residents as it relates to Hypertension and Dementia, potential interference with activities of daily living and med refusals, and able to document use of interventions in EMR weekly x4 and bi-weekly x2. Results of audit will be reviewed and evaluated at QAPI meeting.