Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement the comprehensive care plan for two residents, leading to deficiencies in their care. Resident R306, who was admitted following a left hip surgery, had a care plan that required assistance from two staff members for transfers due to limited mobility and deconditioning. However, an observation revealed that the resident was transferred by only one staff member, Nurse Aide Employee E8, which was confirmed in an interview with the aide. This action was contrary to the care plan's specified interventions, indicating a failure to adhere to the established care plan. Resident R67, admitted with gait and mobility abnormalities, was observed wearing a brace on the right lower leg and complaining of discomfort. The resident's clinical record included a physical therapy note about irritation from the ankle-foot orthotic (AFO), but there was no care plan addressing the use of the AFO. An interview with the Director of Nursing confirmed the absence of a care plan for the AFO, highlighting a lack of comprehensive planning for the resident's needs. These findings demonstrate the facility's failure to develop and implement appropriate interventions as outlined in the comprehensive care plans for these residents.
Plan Of Correction
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual. The resident (R306) that was affected Care Plan was updated to transfer assistance with one staff member after re-evaluation with Rehab Therapist. Employees (E8) was educated and received counseling regarding reviewing the Care plan prior to delivering care. The resident (R 67) was evaluated by the Rehab Therapist and Care Plan updated to include Right Lower Leg AFO. 2. Indicate how the facility will act to protect residents in similar situations. All current residents requiring Transfer Assistance and AFO devices Care Plans have been reviewed and updated. A formal education for Comprehensive Care Planning of Transfer Assistance and AFO devices was initiated by the facility Nurse Educator for all Nursing Staff. 3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur. To ensure that this problem does not occur in the future, the facilities will conduct a formal education for Comprehensive Care Planning of Transfer Assistance and AFO devices was initiated by the facility Nurse Educator for all Nursing Staff. 4. Indicate how it plans to monitor its performance to make sure that solutions are sustained. The Director of Nursing will perform weekly Care Plan audits x4 and then monthly for 3 months to ensure that resident Transfer Assistance Status and Residents requiring AFO devices are appropriate. Results will be submitted and reviewed at Quarterly QAPI meeting for continued compliance. 5. Provide dates when corrective action will be completed. The facility will complete this Plan of Correction_April 4, 2025.