Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident 44 experienced an incident during a shower where staff did not follow the care plan interventions for her known behavior of making false accusations. Despite being agitated and expressing discomfort, the staff continued with the shower instead of stopping and reapproaching later, as outlined in her care plan. The care plan also lacked an intervention for two staff to provide care due to her behavior, which contributed to the incident. Resident 5, who has an implanted pacemaker, did not have a care plan addressing the care or precautions related to the pacemaker or its associated transmitting device. The resident's medical records lacked information about the device, and staff were not adequately informed about its operation or troubleshooting. Additionally, there was no care plan related to the resident's anticoagulation therapy with Eliquis, nor was there evidence of monitoring for side effects such as bleeding, which was only addressed after surveyor questioning. These deficiencies were identified through clinical record reviews and interviews with residents and staff. The facility's failure to develop and implement appropriate care plans for these residents resulted in inadequate care and monitoring, as evidenced by the surveyor's findings and subsequent discussions with the Nursing Home Administrator and other staff members.
Plan Of Correction
1. No residents were harmed. Employee 3 and 6 were educated to reapproach residents when they show signs of agitation. Resident 44 care plan was updated to reflect her plan of care. Resident 5 care plan was updated and reviewed to reflect the plan of care. 2. The Director of Nursing reviewed residents care plans to ensure they reflect their current plan of care. 3. The Director of Nursing provided education to the RNAC and nursing staff regarding the significance of revising care plans to align with the individualized needs of the residents. All updated care plans or resident information will be found on PCC in the Kardex section of the EMR. 4. The Director of Nursing or designee will perform care plan audits weekly for a period of four weeks, subsequently transitioning to monthly audits for three months. The results will be reported at the monthly Quality Assurance meeting for assessment.