Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to update and revise the care plans for two residents to reflect their current care needs. For Resident 9, a quarterly Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact and required substantial assistance for showering and bathing. The resident had a diagnosis of congestive heart failure and a history of falls, with a care plan indicating a preference for showers twice a week. However, physician orders required the resident to receive a complete bed bath daily with specific skin care instructions due to ichthyosis vulgaris. The Director of Nursing confirmed that the care plan needed updating to reflect these changes. For Resident 13, the quarterly MDS assessment showed cognitive impairment and a need for assistance with daily care. The care plan indicated the resident was an elopement risk and required oxygen therapy. However, elopement risk evaluations showed the resident was not at risk, and there was no evidence of oxygen therapy being administered. The Director of Nursing confirmed that the resident was no longer an elopement risk and did not receive oxygen therapy, indicating that the care plans should have been revised accordingly.
Plan Of Correction
Resident #9 order was reviewed and had been followed. The care plan was reviewed and revised to capture the resident specific care needs. Resident #13 the care plan was reviewed and revised. Residents receiving specific care have the potential to be affected. Director of Nursing provided education to the Interdisciplinary team as well as the Minimum Data Set (MDS) coordinator on updating care plans to include specific care needs. Monitoring will be captured through auditing specific care needs. Review 3 clinical records will be reviewed weekly for 4 weeks, then 6 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.