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F0657
D

Failure to Update Care Plan for Hearing Aid Compliance

Brentwood, New York Survey Completed on 01-28-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This deficiency was identified for a resident who had a physician's order to use bilateral hearing aids daily. Despite the resident's noncompliance and frequent removal of the hearing aids, the comprehensive care plan for the hearing deficit was not updated to indicate the resident's behavior. The facility's policy required care plans to be reviewed quarterly, annually, or when there was a significant change in the resident's condition, but this was not adhered to in this case. The resident in question was admitted with diagnoses including Dementia with severe agitation, Anxiety Disorder, and Chronic Obstructive Pulmonary Disease, and had severely impaired cognition. Observations during the survey revealed that the resident was not wearing hearing aids and was unable to hear or respond to greetings. Interviews with staff, including an LPN and the Director of Nursing Services, confirmed that the resident often refused to wear the hearing aids and that the care plan should have been updated to reflect this behavior. The failure to update the care plan was a violation of the facility's policy and regulatory requirements.

Plan Of Correction

Plan of Correction: Approved February 12, 2025 A: Immediate Correction Action 1. Resident #102 who still resides at the facility was affected by this deficient practice. 2. The CCP for resident #102 titled Hearing Deficit was updated to reflect the residents non-compliance with hearing aid usage on 1/24/2025. 3. Charge Nurse #2 was counseled and re-educated on Care Plan timing and revision by the RN Nurse Educator on 2/5/25. B: Identification of Others 1. All residents that reside in the facility with hearing aids have the potential to be affected by this deficient practice. 2. The facility audited all residents that have the potential of same deficient practice and there were no negative findings. C: Systematic Review to prevent re-occurrence 1. The facilities policy titled Care Plan dated 8/2022 was reviewed by the Administrator, Medical Director and DNS and no changes were made. 2. The RN Nurse Educator will re-educate all nurses on Care Plan Timing and Revision. D: Quality Assurance 1. The DNS devised an audit tool to ensure that all care plans are timely and revised according to the facilities policy and procedure. 2. The DNS and or designee will audit the care plans of 10 residents weekly x 3 months and thereafter monthly for 1 year or until 100% compliance is achieved. 3. Any negative audit findings will immediately be addressed by the DNS/ designee with an onsite teaching/in-service, and disciplinary action as needed. 4. The DNS will report the findings of this audit quarterly at the QAPI meeting. 5. The DNS/ designee is responsible for ensuring the correction of this deficient practice.

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