Failure to Develop Comprehensive Care Plan for Resident with Depression
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident diagnosed with Major Depressive Disorder, which included the use of antidepressant medication. This deficiency was identified during a recertification survey, where it was found that the care plan for the resident did not address the diagnosis of Major Depressive Disorder or the administration of Sertraline, an antidepressant medication prescribed to the resident. The facility's policy requires that a comprehensive care plan be developed within seven days of the completion of the Minimum Data Set Assessment, and that it should be updated upon the resident's readmission or during quarterly assessments. Interviews with facility staff revealed that the responsibility for creating and updating care plans was shared among various disciplines, including nursing and social services. However, the care plan for the resident's depression was overlooked by all involved parties. The Director of Nursing acknowledged that the care plan should have been updated during the resident's quarterly assessment and upon readmission, but it was not. This oversight resulted in the absence of a documented care plan addressing the resident's Major Depressive Disorder and the use of antidepressant medication.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: Care Plan for the identified resident was reviewed and updated. Resident #20- A depression care plan was developed and implemented by the charge nurse after review of the medical record and physician orders [REDACTED]. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The Assistant Directors of Nursing/designee will review the medical record of all residents to ensure that residents’ comprehensive care plans are reviewed and revised to reflect accurate plans. Additional corrective actions will be implemented as needed. The Educator/designee will provide additional education to all licensed nursing staff regarding policies and procedures related to reviewing and revising comprehensive care plans to reflect accurate plans. The Director of Nursing/designee will monitor compliance with care plan development and implementation and will: A. Create a report of all [MEDICAL CONDITION] medications to ensure that each resident maintained on a [MEDICAL CONDITION] medication has an active care plan for the medication and its use. B. All affected residents care plans will be reviewed by the Interdisciplinary Team at the Comprehensive Care Plan meetings. C. All care plans for readmitted residents will be reactivated in the EMR, reviewed and revised as needed for the use of [MEDICAL CONDITION] medications. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The facility’s compliance will be monitored utilizing the following quality assurance system: The Assistant Directors of Nursing/designee will audit 10% of all residents to ensure that residents’ comprehensive care plans are reviewed and revised to reflect accurate plans. Findings will be reported to the Director of Nursing on a monthly basis. Additional corrective action will be implemented as needed. The Administrator, Director of Nursing and Medical Director will review and revise, as needed, policies and procedures related to Comprehensive Care Plans. The Educator/designee will provide education to all staff involved in the care planning process regarding the above protocol so that upon readmission, residents’ care plans are reactivated and care plans are reviewed and revised as necessary to reflect accurate care needs. Interdisciplinary Care Planning meeting will be utilized to review that all appropriate care plans are implemented based on residents’ needs. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Assistant Directors of Nursing/designee will audit all care plans of residents who are on [MEDICAL CONDITION] medications monthly for 3 months or until improvement is sustained to ensure that care plans are implemented and resident centered for [MEDICAL CONDITION] medications. The Director of Nursing/designee will report findings to the Facility Quality Assurance/Performance Improvement Committee on a monthly basis for evaluation and follow up to ensure 100% compliance. Additional corrective action will be implemented as needed. 5. Responsible Individual: Director of Nursing