Deficiencies in Comprehensive Care Planning
Penalty
Summary
Sherwood Oaks was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically in the development and implementation of comprehensive care plans for residents. The facility's policy mandates that care plans be individualized and reviewed regularly, yet deficiencies were identified for two residents. The care plans failed to address specific medical interventions and goals related to their conditions, as required by federal regulations. Resident R13, admitted with diagnoses including diabetes, high blood pressure, and stroke, did not have a person-centered care plan addressing the use of a Dexcom G7 Receiver Device for continuous glucose monitoring. Despite a physician's order for the device, the care plan lacked goals and interventions related to its use. This oversight was confirmed by the Director of Nursing during an interview, highlighting a gap in the facility's adherence to its own care planning policy. Similarly, Resident R23, with diagnoses of Parkinsonism, chronic pain syndrome, and polyneuropathy, was receiving antiplatelet medication for CVA prophylaxis. However, the care plan did not include goals and interventions related to this medication. The Registered Nurse Assessment Coordinator confirmed this omission, indicating a failure to incorporate critical aspects of the resident's medical treatment into the care plan. These deficiencies demonstrate a lack of comprehensive care planning for residents with complex medical needs.
Plan Of Correction
1. The care plan for R13 and R23 have been updated to include Dexcom use and anti-platelet medication. 2. All resident care plans were evaluated for the need to add interventions related to Dexcom use and anti-platelet medication. No other issues were found. 3. All RNs and LPNs will be educated by the Director of Nursing or designee regarding the need to care plan Dexcom use and anti-platelet medication. 4. The Director of Nursing/designee will audit care plans weekly for one month or until substantial compliance is achieved to ensure residents with Dexcom monitors and anti-platelet medication are addressed on the comprehensive plan of care. 5. Results will be reviewed at the Quarterly QA Meeting.