Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their specific medical needs. Resident 144, diagnosed with dementia and anxiety disorder, did not have a care plan for dementia until it was identified during the survey. The Director of Nursing initially believed that existing care plans for other conditions were sufficient. Resident 161, who had a cerebral vascular accident and peripheral vascular disease, was observed with enabler bars on his bed, but these were not documented in his care plan or physician orders after returning from the hospital. The Director of Nursing acknowledged that the care plan should have been updated to reflect the use of enabler bars. Resident 221, with heart failure and a history of falls, also had enabler bars attached to the bed, but no care plan was developed for their use. Similarly, Resident 265, who had impaired visual function and received eye injections for macular edema, lacked a care plan addressing her visual needs and treatment by an ophthalmologist. These omissions indicate a failure to ensure that care plans were comprehensive and reflective of the residents' current medical conditions and needs.
Plan Of Correction
This provided submits the following plan of correction in good faith and to comply with Federal regulations. 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. Resident 144's care plan was updated with a dementia diagnosis. Resident 161's current physician orders and care plan have been updated for enabler bars. Resident 221's care plan has been updated for having bilateral enabler bars. Resident 265's care plan has been updated to include a vision care plan. 2. To identify other residents that have the potential to be affected, the DON/designee completed an audit on residents with enabler bars to ensure residents have current orders and care plans in place. The DON/designee completed an audit on residents with a vision diagnosis to ensure they have a vision care plan. The DON/designee completed an audit on residents who have a dementia diagnosis to ensure they have an accompanying care plan for dementia. 3. Nursing staff and social service staff will be educated by staff development/designee on developing/implementing comprehensive care plans. 4. The DON/designee will conduct an audit 1x a week for 4 weeks on new admissions and current residents that have a dementia diagnosis, ordered enabler bars, and a vision diagnosis to ensure they have a care plan developed/implemented for dementia, enabler bars, and vision. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.