Failure to Revise Resident Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident R3, to accurately reflect their current status. Resident R3 was admitted to the facility with diagnoses including encephalopathy, hypothyroidism, and anemia. A review of Resident R3's Minimum Data Set (MDS) assessment, dated 11/18/24, confirmed that these diagnoses were current. However, the Resident Care Plan Summary Report, also dated 11/18/24, included instructions to equip the resident with a device that alarms when the resident wanders, with checks for proper functioning and placement every shift. Despite this, there was no physician order for such a device dated 11/13/24. During an interview on 12/17/24, the Director of Nursing confirmed that the facility did not revise the care plan for Resident R3 as required. This oversight indicates a failure to ensure that the care plan accurately reflected the resident's needs and the interventions required, as there was no documented physician order for the alarm device mentioned in the care plan. This discrepancy between the care plan and physician orders highlights a lapse in the facility's adherence to regulatory requirements for care plan revisions.
Plan Of Correction
The care plan for R3 was revised on 12/17/2024 to reflect care interventions. The order for the device was discontinued prior to the observation. The interdisciplinary team will be re-in serviced by the RDCS/designee on Care Plan Timing and Revision F0657 by 12/26/2024. The Registered Nurse Assessment Coordinator/designee will conduct audits of care plan revisions needing to be made to the comprehensive care plans via the 24-hour report 3 x per week for 4 weeks, then weekly times 2 weeks. Any noted discrepancies will be addressed as appropriate, and results of auditing will be reviewed at the facility Quality Assurance Meeting.