Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to ensure the development and implementation of comprehensive person-centered care plans for two residents, leading to deficiencies identified during a recertification survey. Resident #57, who had diagnoses including diabetes and hypertension, was observed with a chair alarm attached to their shirt, despite their care plan not including the use of such an alarm. Interviews with staff revealed that the resident's care plan and certified nurse aide information sheet did not document the use of a chair alarm, and staff were unaware of its use, indicating a lack of communication and proper documentation. Resident #43, diagnosed with atrial fibrillation, heart failure, and dementia, was receiving an anticoagulant medication, Eliquis, as per physician orders. However, their care plan did not include specific interventions for the use of this blood-thinning medication, such as monitoring for bleeding or bruising. Interviews with nursing staff and management confirmed that the care plan should have included these interventions, but they were missing, highlighting a gap in the care planning process. The facility's policies required care plans to be updated with accurate information and reviewed regularly, but these requirements were not met for the residents in question. The lack of comprehensive care plans for both residents indicates a failure in the facility's processes to ensure that all necessary interventions and safety measures are documented and communicated to staff, potentially impacting the quality of care provided to the residents.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F656- Develop/Implement Comprehensive Care Plan: Crouse Community Center will ensure the development and implementation of a person-centered Comprehensive Care Plan. Corrective action: Resident #43 anti-coagulant use was identified and implemented into the Comprehensive Care Plan for risk of bleeding or bruising on (MONTH) 14, 2025. Resident #57 has been determined not at risk for falls; therefore, chair alarm was removed and staff was educated on his plan of care on (MONTH) 6, 2025. Other residents: All other residents were reviewed for anti-coagulant use, and the Comprehensive Care Plan was updated for all of those residents to include at risk for bleeding or bruising complications to be monitored. All other residents in the facility will have a fall risk assessment completed and have appropriate interventions implemented and added to their Comprehensive person-centered Care Plan. Systemic Changes: All new residents admitted on anti-coagulant therapy or any other resident with a new order for anti-coagulant therapy will have a Comprehensive Care Plan implemented or updated to include at risk for bleeding or bruising complications to be monitored. This will also be communicated to the CNA staff utilizing the CNA information sheets. Moving forward, fall risk assessments will determine appropriate interventions and will be updated on the CNA information sheets and the Comprehensive person-centered Care Plan. All staff educated on following the CNA information sheets and the Comprehensive person-centered Care Plan. Monitoring: Audits will be conducted by the Director of Nursing monthly on Care planning for anti-coagulants with a 100% compliant threshold. This audit will be presented to QAPI monthly. Audits will be conducted by the Director of Nursing to include alarm use and Care planning. This will be done by checking physician orders [REDACTED]. This audit will be done monthly with a 100% compliant threshold and reported monthly to QAPI. Responsible Party: Director of Nursing