Care Plan Inaccuracies for Two Residents
Penalty
Summary
The facility failed to review and revise the care plans of two residents to accurately reflect their current medical status. For Resident 161, the care plan inaccurately stated a 'full code' status, despite the resident's POLST, advance directive, and physician orders indicating a 'do not resuscitate' (DNR) status. This discrepancy was noted in the care plan created in September 2024, and although the code status was clarified to DNR in October 2024, the care plan was not updated accordingly. The Director of Nursing (DON) confirmed that the care plan should have matched the resident's documented code status. For Resident 327, the care plan did not include information regarding the presence or care of a loop recorder implant, which was ordered to be monitored and plugged in each shift starting February 2025. Despite the loop recorder monitor being observed on the resident's nightstand, the care plan lacked any mention of this device. The DON acknowledged that the care plan should have included details about the loop recorder implant, as per the physician's orders.
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 161's care plan was updated to reflect residents choice to be a DNR. Residents 327's care plan was updated to reflect the information on the loop recorder monitor as well as the ordered care for the loop recorder implant. 2. To identify other residents that have the potential to be affected, the DON/designee conducted an audit on resident care plans to ensure they match the residents code status. The DON/designee conducted an audit on residents with a cardiac monitor device to ensure they have a care plan that includes the information on the device and the proper care/monitoring it requires. 3. Nursing staff and social service staff will be educated by staff development/designee on care plan revisions, updating code statuses in the care plan and implementing care plans on cardiac monitoring devices. 4. The DON/designee will conduct an audit 1x a week for 4 weeks on new admissions and any residents that updated their code status to ensure their care plan reflects their code status. The DON/designee will conduct an audit 1x a week for 4 weeks on new admissions that have a cardiac monitoring device to ensure their care plan identifies the device as well as the information how to care/monitor the device. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.