Deficiencies in Care Plan Implementation and Communication
Penalty
Summary
The facility failed to implement an individualized comprehensive care plan for a resident reviewed for safety precautions. The resident was admitted with diagnoses including fluid disturbances and speech issues. The Minimum Data Set (MDS) assessment indicated the resident was rarely or never understood. Despite the care plan specifying the use of padding on bed rails for safety, observations revealed the rails were unpadded during the day. A Certified Nursing Assistant (CNA) confirmed the absence of padding and was unaware of the reason. The Restorative Unit Manager stated the padding was only applied at night when the resident became agitated, contrary to the care plan's requirements. Another deficiency was identified for a resident reviewed for communication needs. This resident, who had intact cognition and primarily spoke Spanish, expressed a desire for an interpreter when communicating with healthcare staff. The MDS assessment noted her social isolation and dependence on staff for personal care. However, her care plan did not address her communication needs or preference for an interpreter. An interview with the resident revealed a recent incident where a nurse administered a discontinued medication and mishandled another medication, leading to distress. The resident preferred Spanish-speaking staff and had communicated this preference, but it was not reflected in her care plan. The facility's policy on comprehensive care plans emphasizes the development of person-centered plans that incorporate residents' personal and cultural preferences. Despite this, the care plans for both residents failed to address their specific needs as identified in their assessments. The MDS Coordinator acknowledged the oversight in the communication care plan and confirmed that the resident's preference for an interpreter was known but not documented in the care plan.
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: For Resident #92, the pads were placed per the Resident's care plan. Resident #92 was reassessed to ensure all precautions were properly implemented. CNA Q was re-educated on the importance of following care plan interventions, especially for residents with. For Resident #56, the care plan was updated to reflect the resident's primary language of Spanish with the intervention of utilizing an interpreter as indicated. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents with a diagnosis of and Residents who do not speak English proficiently have the potential to be affected. A facility-wide audit of all residents with was conducted to ensure appropriate interventions were care planned and in place. MDS Coordinator conducted an audit of all residents with limited English proficiency to ensure their communication needs were appropriately care planned. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Nurse leadership team, including Director of Nursing, Assistant Director of Nursing, Unit Managers, and MDS Nurses received in-service training on by Regional Nurse on the requirement for comprehensive Resident Centered care plans with focus on Residents with and/or limited English proficiency. Starting on all Direct Care staff (RNs, LPNs, and C.N.A.S) will receive mandatory training on the importance of following individualized care plan interventions, ensuring safety interventions are in place for precautions per plan of care, and on communicating with Residents with limited English proficiency per plan of care to include use of Propio 1 Interpreter Line. 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. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing or designee will conduct weekly audits of 5 Residents with or Limited English Proficiency for four weeks, then 10 monthly for at least three months, to ensure care plans are accurately implemented and followed. Any discrepancies found will result in immediate correction and staff re-education. Audit results will be reviewed in the facility's monthly Quality Assurance and Performance Improvement (QAPI) meetings. (e) The compliance date is.