Failure to Implement Care Plan Interventions for Residents
Penalty
Summary
The facility failed to provide appropriate interventions for two residents with a history of major injuries. Resident #1, who had severe cognitive impairment and required assistance with transfers, was not wearing hipsters as per the care plan, which were intended to prevent injuries. The resident had a history of gait and balance problems, poor communication, and hearing issues. Despite these risks, staff did not ensure the resident was wearing the hipsters, and the resident sustained an unwitnessed fall resulting in a fracture that required surgical repair. Resident #2, also with severe cognitive impairment and decreased physical mobility, was at risk for falls and related injuries. The care plan required floor mats to be placed on both sides of the bed to prevent falls. However, during observations, no floor mats were found in the resident's room, and staff were unaware of the requirement. The resident had previously been found on the floor beside the bed, and later sustained a fracture requiring hospital treatment. The deficiencies were identified through observations, interviews, and record reviews, revealing that staff were not following the care plans for these residents. The Director of Nursing was unaware of the specific interventions required for these residents, and there was no documentation verifying that the interventions were being completed daily. This lack of adherence to care plans and communication among staff contributed to the residents' injuries.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #1, Dycem was placed in resident wheelchair on Care plan and Kardex updated. Resident #1, Hipsters were put on resident, on Care plan and Kardex updated. Resident #2, floor mats were placed on each side of the bed on Educated CNAB on resident #1 on interventions. Educated CNAC on resident #2 on intervention. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; A Quality review that contains look period of 60 days was completed on to ensure residents with that the care plans, kardex and interventions are in place. Issues or concerns were addressed as they were identified. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Director of Clinical Services/Designee re-educated the licensed nurses and certified nursing assistants on the components of this regulation with an emphasis on; management policy and procedure, Care plan and kardex to be updated with interventions, intervention to be in place. During clinical morning meeting Director of Nursing/Designee will review resident with to ensure care plan, kardex and intervention in place. Newly hired licensed nurses and certified nursing assistants will receive education in orientation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, l.e., what quality assurance program will be put in place; The facility Director of Clinical Services/designee will conduct a weekly audit of 5 residents to ensure interventions are care planned, kardex updated and intervention in place weekly x 4 weeks, and then every 2 weeks x 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the Divisional Director of Clinical Services when completing their systems review.