Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia, identified as Resident R46. The deficiency was identified through a clinical record review and staff interview, which revealed that Resident R46, admitted on December 21, 2023, with a diagnosis of dementia, did not have a care plan with measurable goals and interventions to address their dementia care needs. The facility's dementia policy, dated November 2018, requires the interdisciplinary team to create a resident-centered care plan to maximize function and quality of life for individuals with confirmed dementia. Despite this policy, the review of the Minimum Data Set (MDS) indicated that Resident R46 was receiving antipsychotic medications, yet there was no corresponding care plan addressing their dementia care. The Director of Nursing confirmed that residents diagnosed with dementia should have a care plan in place.
Plan Of Correction
Resident 46 care plan was reviewed and updated as needed. Residents with a diagnosis of dementia care plans were reviewed for care plan with measurable goals and interventions to address their care and treatment needs. Staff development nurse/designee re-educated licensed nurses and social services on comprehensive care plans to address individualized needs of residents with dementia. Unit managers and social services will audit random care plans with residents with a diagnosis of dementia to ensure that they have an individualized care plan to address dementia care weekly x4 and monthly x2 and report findings to QAPI committee monthly.