Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who required substantial assistance with grooming and personal care. The resident, who was admitted with diagnoses including failure to thrive, functional debility, mild acute kidney injury, skin rash, and frequent falls, expressed that they had requested assistance with shaving and hair trimming, but these needs were not addressed. Upon review, it was found that there was no documented evidence of a care plan addressing Activities of Daily Living for this resident, despite the facility's policy requiring such plans to be developed and implemented. Interviews with facility staff revealed a lack of clarity and responsibility regarding the development of care plans. The Registered Nurse Manager indicated that the admitting nurse should have created the care plan within 48 hours of admission. However, the Assistant Director of Nursing and the Rehabilitation Director both acknowledged that the care plan for Activities of Daily Living was missed. The Rehabilitation Director stated that the Occupational Therapist was responsible for creating the self-care and functional mobility care plan, but it was not completed. This oversight led to the deficiency noted during the survey.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1) Immediate actions taken for those residents identified: Resident #238’s Care plan was correctly updated reflecting the appropriate plan of care including Activities of Daily Living Care plan, Mobility care plan and Range of Motion care plan. 2) How the facility identified other residents: All residents can be affected by this deficient practice. The Director of Rehabilitation audited ADL care plan of all residents and no other Residents were affected. 3) Measures put into place/System changes: PT, OT, ST Supervisors and RNs/Nursing Supervisors/Unit Managers received in-service from the Director of Rehabilitation with regards to timely implementing and developing all ADL/Mobility/Range of motion care plans upon admission/readmission/start of care and the policies which includes Activities of Daily Living Care Plan, Mobility care Plan and Range of Motion Care Plan. ADL Functional Abilities Policy and Procedure was reviewed and kept the same. This includes Activities of Daily Living Care Plan, Mobility Care Plan and Range of Motion Care Plan. 4) How the corrective actions will be monitored: An audit tool by the Director of Rehabilitation was developed to monitor compliance in timely implementation of care plans. Director of Rehabilitation/Designee will audit on a weekly basis for a year to ensure compliance and timely establishing and implementing the care plans. The Director of Rehabilitation is responsible for ensuring the corrective action is implemented and is responsible for the implementation and monitoring of the plan. This audit will be submitted to Administrator and presented to the quarterly QAPI meeting.