Care Plan Deficiencies in Resident Participation and Documentation
Penalty
Summary
The facility failed to ensure the participation of residents in the care planning process and did not adequately review and revise care plans for several residents. Resident 4 was not invited to care plan meetings, as confirmed by both the resident and the Nursing Home Administrator (NHA). Despite having multiple care conferences, there was no documentation of Resident 4's attendance or invitation, which is against the facility's policy that supports resident participation in care planning. Resident 28's care plan did not include documentation of a skin rash or interventions for its treatment, despite the resident having a rash for about six months and receiving treatment for it. Additionally, Resident 28 expressed a preference for wearing a bra, which was not addressed in the care plan. The NHA acknowledged that the care plan was not updated upon the resident's re-admission after a hospital discharge, leading to missing personalized care information. Resident 37 also had a skin rash that was not documented in their care plan, despite having physician orders for treatment. Similarly, Resident 58's care plan lacked documentation of antipsychotic medication use and the target behaviors it was intended to manage. The Director of Nursing (DON) confirmed that these omissions were not in line with the facility's expectations for care plan documentation.
Plan Of Correction
R4 unable to retroactively correct care plan. R4 was recently offered to participate in the care planning process and declined on 2/19/25 invited by the Activities Director, documented on clinical record of resident's choice to decline. R4 acknowledged understanding of residents right to participate in the care planning process. R28 unable to retroactively correct clinical record of the presence of the rash, it is confirmed the rash was resolved. R28 care plan was reviewed and updated to reflect all care areas specific to the resident preferences, such as wearing a bra daily. Section V of the MDS care area assessment summary for R28 was also updated for assistance with eating, oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, transfers, and mobility, along with preference of importance to choose clothing. R28's care plan specifics for ADL self-care performance also reviewed for additional interventions and updated. R37 care plan for rash was updated on 2/6/25 for the treatment of the rash. R58 care plan was updated on 2/17/25 to reflect the antipsychotic medication was being utilized to manage residents identified targeted behaviors and on 2/5/25 it was indicated on the R58's care plan that it was updated to reflect antipsychotic use. R4, R28, R37 and R58 currently reside at the facility and no adverse effects related to practice. The facility has determined that all residents have the potential to be affected by this deficient practice. The DON, Shift Supervisors, Social Services, Activities Director and MDS Coordinator will audit all care plans to ensure the comprehensive care plans are being updated or new care plans completed for all residents including readmissions from hospital to reflect individual preferences and Resident-specific ADL information to include interventions by March 14, 2025. To prevent other residents from being affected the DON will re-educate the Social Services and Activities Director, Activities Director and Shift Nurse Supervisors by March 14, 2025 on the requirements and policy of the Comprehensive Care Plan and quarterly review assessments, as well as compliance with the Care Plan Revisions. Additional training to include residents right to be invited to Comprehensive Care plans and document that the invite was offered or refused, along with documentation that resident understands and acknowledges their rights to attend care plan meetings. The DON will also educate on directives of physician orders, documenting the identification of any medical concerns or progress along with interventions and treatment follow up for residents. The DON and NHA will also in-service the IDT Team on communication of any new information or updates in the daily standup and clinical meetings to include, change of condition or significant change to be updated in the resident's care plan. An audit will be conducted by the DON, Activities and/or Social Services Director to ensure comprehensive care plans and assessments are completed timely, updated/revised for all residents weekly x 4 then monthly for 2 months, until 100% is achieved. Findings of the audits will be reported monthly to the QAPI committee meeting to ensure compliance is obtained and maintained.