Care Plan Deficiencies for Three Residents
Penalty
Summary
The facility failed to update the care plans for three residents, resulting in deficiencies in accurately reflecting their current status and care needs. Resident R1, who was admitted with diagnoses including peripheral vascular disease, heart failure, and dependence on renal dialysis, had a care plan that did not address specific nutritional problems, goals, and interventions related to a chronic stage IV pressure ulcer, therapeutic diet, and dialysis. This was confirmed by a registered dietitian during an interview. Resident R50, diagnosed with anemia, hypertension, and quadriplegia, consistently refused tube feedings, as documented in nursing progress notes and the medication administration record (MAR). However, the resident's care plan did not include interventions for the refusal of tube feedings, a deficiency confirmed by the Nursing Home Administrator. Resident R115, admitted with renal insufficiency, atrial fibrillation, and heart failure, had a physician order for PICC line care that was not reflected in the care plan. Additionally, the care plan did not address the resident's refusal of medications and care, as noted in progress notes. The Nursing Home Administrator and Director of Nursing confirmed the care plan's deficiencies in addressing the PICC line care and medication refusal.
Plan Of Correction
Resident R1's care plan has been updated to include focused nutritional interventions. No negative outcomes were identified as a result of the missing care plan. Resident R50 will not be returning to the facility. The care plan has been closed. Resident R115 was discharged from the facility and had no negative outcomes as a result of the CarePlan not being updated. All resident Care Plans will be reviewed for accuracy. The DON or designee will educate all licensed nursing staff, social services, dietician, and MDS coordinators on the requirements of updating the comprehensive care plans. The DON or designee will audit five resident care plans weekly x8 to ensure updates are completed as needed. Results will be reviewed through QAPI for further recommendation.