Failure to Address Anxiety in Resident Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive and individualized care plan for a resident with anxiety, as required by regulations. The care plan did not include goals, objectives, or interventions related to the resident's anxiety, despite the resident's medical history and recent incidents indicating a need for such measures. The resident, identified as having anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, gastrostomy status, end-stage renal disease, and cognitive communication disorder, experienced severe anxiety and was at risk for falls. A fall incident report revealed that the resident removed their tracheostomy tube and became hypoxic due to confusion and agitation. Nursing progress notes documented the resident's severe anxiety and risk for falls, noting behaviors such as pulling at hand mitts and kicking legs over the side of the bed. Despite these observations, the resident's care plan lacked specific strategies to address the anxiety, which contributed to the deficiency identified by the surveyors.
Plan Of Correction
1. R1 care plan has been updated to include goals, objectives and interventions related to anxiety. 2. Director of Nursing/Designee will audit residents with a current diagnosis of anxiety to ensure interventions are present in care plan. 3. NHA/Designee will complete care plan education to the Interdisciplinary Team. Random weekly audits x 4 and monthly x 3 will be completed. 4. QAPI committee will review trends and make recommendations for further audits.