Failure to Update Resident's Care Plan for Transfer Assistance
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was accurately reviewed and revised to reflect the resident's current status. Specifically, the care plan for a resident with diagnoses of Paraplegia, Human Immunodeficiency Virus, and Bipolar Disorder was not updated to reflect the resident's need for partial/moderate assistance with one-person physical assist and a sliding board for transfers. Instead, the care plan inaccurately documented the requirement of a Hoyer lift with two-person assistance for chair/bed-to-chair transfers. The discrepancy arose when the Functional Status Endorsement from Rehab to Nursing indicated the need for a one-person assist with a sliding board, which was acknowledged by Registered Nurse #5. However, the care plan and Certified Nursing Assistant Task instructions were not updated to reflect this change. Interviews with the Director of Rehabilitative Therapy and Registered Nurse #5 confirmed the oversight, with the latter acknowledging responsibility for updating the care plan but failing to do so. The Director of Nursing also confirmed that Registered Nurse #5 was responsible for the update.
Plan Of Correction
Plan of Correction: Approved January 22, 2025 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 #217 - The ADL care plan and C.N.A. instructions/tasks were updated by the charge nurse to reflect the resident’s need for partial/moderate assistance with 1-person physical assist and a use of a sliding board. The Educator issued an educational counseling to all staff involved on the policy of care planning to ensure that care plans are reviewed and revised at least quarterly, with a change in condition and as needed. 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 Assistant Directors of Nursing/designee conducted a facility-wide audit of all residents to ensure that all endorsements to Nursing from Rehabilitation were accurately reflected on the comprehensive care plan and C.N.A. instructions/tasks, at least quarterly, annually, and as needed. The Educator/designee will provide additional education to all licensed nursing staff on the “Comprehensive Care Planning” policy, and updating of C.N.A. instructions/tasks, with emphasis on the review and revision of rehabilitation endorsements to nursing in a timely manner after each assessment, at least quarterly, annually, and as needed. 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 Administrator, Director of Nursing, and Medical Director will review and revise, as needed, policies and procedures related to the review and revision of Comprehensive Care Plans after each assessment, at least quarterly, annually, and as needed. The Educator/designee will provide additional education to all staff involved in the care planning process regarding the above protocol so that residents’ care plans are reviewed and revised to reflect accurate plans with emphasis on updating the care plans and C.N.A. instructions/tasks after each Rehabilitation assessment and endorsement to Nursing. Licensed Nursing Staff will audit the care plans at the Comprehensive Care Plan meetings to ensure that care plans of residents are reviewed and updated based on the resident’s current condition and needs. Any findings will be reported to the Director of Nursing/designee for correction. 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 10% of all residents weekly for 3 months or until improvement is sustained to ensure that care plans and C.N.A. instructions/tasks are implemented and revised timely in regards to Rehabilitation endorsements to Nursing. 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