Lack of Communication with External Treatment Center
Penalty
Summary
The facility failed to maintain ongoing communication and collaboration regarding the care and services for a resident who required specific treatments at an external center. The resident's medical record showed no documentation of communication between the facility's nursing staff and the external center from a specified period. The Unit Manager expected the facility's Communication Record to be completed and sent with the resident to the center, and for the nursing staff to review and include the returned form in the resident's medical record. However, there were no Communication Records or any other documentation of communication with the center in the resident's medical record. Interviews with staff from both the facility and the external center revealed that the facility used to send a binder for communication, but it had not been used for six months or more. The Clinical Manager and Clinical Nurse at the center confirmed that they had not received regular communication from the facility after each session, and sometimes faced difficulties in reaching the resident's nurse at the facility. The Assistant Director of Nursing acknowledged the importance of communication for coordinating care and verified the absence of documentation in the resident's electronic medical record, indicating a lapse in the facility's communication practices.
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: The Unit Manager contacted the provider to obtain Resident #12's updated treatment records, including recent lab results, treatment schedules, and any noted concerns. Resident #12's care plan was reviewed and updated to reflect current care needs, including communication protocols between the facility and the provider. (b) Identification of other residents having the potential to be affected was accomplished by: All residents receiving have the potential to be affected. A facility-wide audit was conducted to identify all residents receiving and assess the adequacy of communication and documentation related to their care. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Licensed staff (RNs and LPNs), including unit managers, received education on care coordination, proper documentation, and the importance of interdisciplinary collaboration. All Licensed staff (RNs and LPNs), including unit managers will be in-service by Any Licensed staff (RNs and LPNs), including unit managers 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 staff (RNs and LPNs), including unit managers 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 all residents' records for one month, ensuring accurate documentation and proper communication with providers, followed by monthly audits of 3 residents' records for an additional three months. Audit results will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, with corrective actions taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) The date of compliance is