Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by regulations. Resident 7, who was cognitively intact and had multiple medical conditions including coronary artery disease, congestive heart failure, and diabetes, did not have care plans addressing her diabetic needs, cardiac needs, or the use of a cardiac pacemaker. Despite having physician's orders for various medications and treatments, there was no documented evidence of care plans to manage these conditions. Resident 16, who was cognitively impaired and had a diagnosis of epilepsy, was receiving anticonvulsant medication. However, the facility did not develop a care plan to address the resident's seizure disorder and the need for anticonvulsant medication. This lack of documentation was confirmed by the Registered Nurse Assessment Coordinator during an interview. Resident 33, who was mildly cognitively impaired and had multiple mental health diagnoses including PTSD, did not have a care plan addressing his PTSD, triggers, and coping strategies. Although the resident was receiving routine psychological services and had a trauma assessment completed, the facility failed to document a care plan for these needs. The Registered Nurse Assessment Coordinator confirmed the absence of such a care plan during an interview.
Plan Of Correction
Resident #7, 16, 33 care plans reviewed and revised to capture resident centered goals and interventions implemented. Residents who require a resident centered care plan have the potential to be affected. Director of Nursing provided education to interdisciplinary team as well as Minimum Data Set (MDS) coordinator on creating resident centered care plans. Monitoring will be captured through auditing specific care needs. Up to 4 clinical records will be reviewed weekly for 4 weeks, then up to 8 clinical records twice monthly for 2 months. The audits will be conducted by the Director of Nursing or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.