Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and implemented to address the medical, physical, mental, and psychosocial needs of three residents. Resident #27, who was receiving oxygen therapy as per physician orders, did not have the use of oxygen or appropriate interventions included in their care plan. Despite observations of the resident receiving oxygen, the care plan lacked goals and interventions related to oxygen use. Resident #81, diagnosed with cerebral vascular accident and right-sided hemiplegia, had a physician order for a right-hand splint to be used during waking hours. However, multiple observations revealed the splint was not in use, and the resident reported not having it for months. The care plan included the use of the splint but did not document any refusal of care or reasons for its absence. Interviews with staff indicated a lack of awareness and documentation regarding the splint's status and maintenance. Resident #108, admitted with multiple diagnoses including anemia and depression, had a care plan that identified several problem areas but lacked specific interventions for each. The care plan did not include interventions for anemia, pain management, antidepressant use, skin integrity, bladder incontinence, visual impairment, falls, or anticoagulant therapy. The Registered Nurse Manager acknowledged the incomplete care plan, indicating a failure to provide comprehensive guidance for the resident's care needs.
Plan Of Correction
Plan of Correction: Approved March 12, 2025 1. Conducted an immediate review of the care plans for all affected residents. Updated the care plans to reflect individualized needs, preferences, interventions, and goals. Communicated changes with interdisciplinary team members and residents to ensure alignment. 2. Reviewed documentation to ensure care plans are current, accurate, and person-centered. Resident #27, #81, and #108 care plans were updated on 02/20/2025 to reflect intervention. All residents' care plans were audited on 03/10/2025. 3. Conduct mandatory training for all nurse managers, clinical coordinators, and interdisciplinary team members on proper care plan development and reinforce training on resident-centered planning, assessment accuracy, and regulatory requirements. Reviewed Interdisciplinary Care Plan. Implemented a standardized checklist for care plan completeness and accuracy. 4. Monthly care plan audit will be completed, and the results of audits will be presented to QAPI for three months. The committee will determine the frequency of the audit thereafter. Responsible party: Director of Nursing