Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as required by federal regulations. Resident 112, admitted with chronic kidney failure, had a care area assessment indicating the need to address urinary incontinence in the care plan. However, the quarterly MDS summary showed frequent urinary incontinence without any interventions documented in the care plan. Similarly, Resident 115, diagnosed with epilepsy and rheumatoid arthritis, also had a care area assessment noting the need to address urinary incontinence. The quarterly MDS summary confirmed frequent incontinence, yet no interventions were included in the care plan. In an interview, the Director of Nursing confirmed the absence of documented interventions for the identified care areas in the residents' care plans. This deficiency was previously cited in March 2024, indicating a recurring issue with the facility's compliance in developing and implementing comprehensive care plans that address individual resident needs as identified in their comprehensive assessments.
Plan Of Correction
1. The care plans of Residents 112 and 115 were updated to reflect urinary incontinence. 2. Current residents identified with incontinence on the most recent MDS have been reviewed to verify incontinence needs are addressed in the care plan. 3. NPE or designee will reinservice licensed nursing staff on the process for developing care plans that address the individual resident needs as it relates to incontinence. 4. DON and/or designee will conduct weekly audits x 8, then monthly x 2 of residents identified with urinary incontinence to verify a care plan is in place. Results of the audits will be presented at the QAPI meetings for review and/or recommendations.