Deficiencies in Resident Care and Communication
Penalty
Summary
The facility failed to effectively manage and communicate the health care needs of Resident #42, who was experiencing severe cramps and spasms. Despite the resident's repeated complaints and visible discomfort, the staff did not evaluate the effectiveness of interventions or provide appropriate treatment. The care plan required staff to monitor and report symptoms, but there was inconsistency in documentation and a lack of medication orders for cramps or spasms. Observations showed the resident experiencing significant discomfort, yet the staff did not take timely action until surveyor intervention prompted a medication order. Additionally, the facility did not ensure timely and adequate nail care for Residents #6 and #61. Both residents had excessively long nails with debris underneath, which were not addressed according to the care plans. The staff responsible for nail care were unclear about their duties, leading to inconsistent and inadequate care. Resident #6 was observed scratching an open area on her cheek, and Resident #61 expressed dissatisfaction with the length of his nails, indicating a lack of routine maintenance. Furthermore, the facility failed to follow physician orders for Resident #61's wound care. The resident's right heel was not offloaded as instructed, and the dressings were not changed daily as required. Observations revealed that the dressings had not been updated, and the Treatment Administration Record inaccurately documented that care had been provided. This oversight resulted in the resident having a malodorous dressing with drainage, indicating a failure to adhere to treatment protocols.
Plan Of Correction
#1 Tag Management What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. The physician was notified of the resident's complaint of spasms and an order obtained for relaxant on. Resident was referred to Management practitioner and evaluated on and an as needed order for was obtained. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. An audit of all residents was done to verify they have active orders for, assessment on. Nursing staff will be reeducated to report all symptoms to primary physicians and Management provider when identified by. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur. Residents will have assessment by licensed nurse every shift to identify incidence of for timely intervention by CNAs reeducated to immediately report any complaints by residents of or discomfort to the floor nurse and immediately by. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. Weekly quality review will be conducted by DON or designee weekly x 4, then bi-weekly x 2 then monthly x 1. Quality reviews will be entered by DON in QAPI for monitoring x 3 months or until substantial compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. #2 and #3 Tag ADL Care: Nail grooming not performed for two residents #6 and #61 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #6, nails were cut and cleaned during survey. Resident #61, nails were cut and cleaned during survey. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. An audit of all residents' nails was conducted on to identify other residents who may be affected by deficient practice. Any exceptions found were addressed at time of audit. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur. Nursing staff educated re residents' nail grooming and cleanliness during daily ADL care by. Weekly audits x 4 weeks will be conducted, then, bi-weekly x 2, then monthly x 1 to identify any deviation from the compliance plan by. Guardian angels will do weekly checks of assigned residents' nails during their routine rounding for need of grooming and report need to Unit Managers for care by. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The plan will be submitted to the QAPI process for monitoring and review x 3 months or until substantial compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. #4: Quality of Care: care was not completed as ordered; care was documented as done. What corrective action(s) will be implemented for those residents found to have been affected by the deficient practice. The physician was informed by the Unit manager of the order for care not being executed, on /24 for resident #61, a new order for PRN obtained and care performed on. The resident's was evaluated by care on and showed no adverse outcome from missed. How will you identify other residents who have the potential to be affected by the same deficient practice and what corrective action will be taken. DON and Unit managers completed an audit of all similar residents to identify any other residents affected by the deficient practice on. The audit revealed that no other residents were affected by the deficient practice. What measures will be implemented or what systemic changes will you make to ensure that the deficient practice does not recur. All licensed nurses will be reeducated on care policy and procedures and on following physicians' orders by. All licensed nurses will be reeducated on nursing documentation of provision of care in residents' medical records only after the care is completed by. Weekly quality review of care provision and documentation will be conducted by DON/designee of 5 residents with x 4 weeks then bi-weekly x 2 then monthly x 1 by. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. Results of quality review by DON/designee will be introduced in the QAPI process for monitoring and review for 3 months or until substantial compliance with care policy. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and for executed solely because it is required by the provisions of federal and state law.