Failure to Implement Adequate Care Plans and Supervision
Penalty
Summary
The facility failed to revise and implement appropriate interventions for two residents, leading to deficiencies in their care. Resident #3, who had severe cognitive impairment, hearing loss, and vision issues, experienced multiple falls. Despite being dependent on staff for various activities, the care plan did not include necessary interventions such as frequent checks or appropriate supervision. The resident's care plan was not updated to reflect her need for constant supervision, and interventions like offering toileting after meals were not implemented. The resident's daughter expressed concerns about the lack of supervision and the resident's tendency to attempt activities independently, which were not adequately addressed by the facility. Resident #51, who also had severe cognitive impairment and required substantial assistance for daily activities, experienced falls in the facility's TV room. The care plan included the use of a dycem to prevent sliding from the wheelchair, but it was not consistently used or documented in the resident's care plan. Staff were unaware of the dycem's absence, and the resident's care plan did not reflect the need for increased supervision during times of behavioral changes. The facility's failure to ensure the dycem was used and to provide adequate supervision contributed to the resident's falls. The facility's policies on accidents and supervision, as well as comprehensive care plans, were not effectively implemented. The guidelines required communication and documentation of interventions across all disciplines, but this was not done. The care plans for both residents lacked necessary interventions, and staff were not adequately informed of their responsibilities. The facility's failure to update care plans and ensure staff were aware of and implemented necessary interventions led to the deficiencies observed.
Plan Of Correction
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. (a) Immediate action(s) taken for the resident(s) found to have been affected include: New risk evaluations were completed for Resident #51 to reflect accurate information, and their care plans and Kardex's were updated to reflect accurate risk assessments, with appropriate and individualized prevention interventions implemented. Resident #3 is no longer residing at the facility. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents who have had a have the potential to be affected. The MDS Coordinator and Unit Managers conducted a facility-wide audit of risk assessments and care plans for residents with a score of 12 or less to identify any discrepancies. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Direct Care staff (RNs, LPNs, and C.N.A.S) staff will receive mandatory training regarding review and use of Care Plan/Kardex prior to providing care to Residents. This education will also be completed upon hire and at least annually. All Direct Care staff will be in-service by. Any Direct Care staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Direct Care staff will be in-service by the ADON during their orientation. Starting on all Licensed nurses (RNs and LPNs) and MDS staff on the proper completion of risk assessments, individualized care planning, and the importance of ensuring interventions are documented in the Kardex. All Licensed nurses (RNs and LPNs) and MDS staff will be in-service by. Any Licensed nurses (RNs and LPNs) and MDS staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed nurses (RNs and LPNs) and MDS staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or Designee will review a sample of five residents risk evaluations, care plans and Kardexs weekly for four weeks, then monthly for three months to ensure continued compliance. Any discrepancies identified will be corrected immediately, and trends will be addressed through additional staff training or process adjustments. Findings will be reported in the monthly QA/QAPI meeting for further review and action as needed for a minimum of 3 months. (e) Date of compliance