Deficiencies in Care Plan Development and Accuracy
Penalty
Summary
The facility failed to ensure accurate and developed care plans for two residents, leading to deficiencies in their care. Resident #2 was admitted with diagnoses including generalized wasting and reduced mobility. The resident was found on the floor by a staff member, who failed to report the incident. The care plan for Resident #2, which should have been updated to reflect necessary interventions after the incident, was not revised. The Director of Nursing (DON) confirmed that the care plan was essential for staff to know the resident's plan of care, but no interventions were put in place after the incident. Resident #3, admitted with ataxia and reduced mobility, also had deficiencies in their care plan. The resident experienced an incident, but the care plan was not updated with interventions to address the situation. The DON stated that interventions were supposed to include keeping the resident in the common area while awake and ensuring personal items were within reach. However, these interventions were not implemented in the care plan after the incidents, leading to a lack of proper care management for the resident.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance. 1. Residents #2 and #3 had a resident centered comprehensive care plan updated to reflect changes identified related to interventions. 2. A quality review of current residents comprehensive care plans was completed by Care Plan Coordinator/Designee to ensure comprehensive care plans are developed and implemented regarding interventions. Issues or concerns, if any, were addressed as they were identified. 3. All Interdisciplinary care plan team members responsible for writing care plans re-educated on the facility's policy and procedure for developing Comprehensive Care plans; Development and Implementation of a new intervention for each, and review of interventions for appropriacy. Direct care staff re-educated on Kardex review for interventions and reporting non-compliance and/or ineffectiveness of interventions. 4. Director of Clinical Services (Nursing)/Designee will review new admission records for initiation of Baseline Care Plan to make certain those identified to be at risk for have interventions/safety measures, five times a week x 4 weeks and once weekly x 8 weeks, then as needed as indicated. Director of Clinical Services/Designee will review records of residents who sustain to make certain documentation includes Change in Condition, Physician Notification, Responsible Party Notification, Care Plan Update with intervention and placement on Kardex five times a week X 2 weeks, three times a week X 4 weeks, twice a week X 2 weeks, and then weekly x 4 weeks, and as needed as indicated. Care Plan Coordinator will review care plans weekly in accordance with care plan review schedule. All care plans will be updated as indicated. The findings of these quality reviews are to be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months, or until committee determines substantial compliance.