Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive activities care plan for a resident, identified as Resident #12, who expressed feelings of loneliness and a desire for in-room activities. Despite the resident's expressed preferences for certain activities, such as going outside for fresh air and participating in religious services, there was no documented evidence of an activities care plan in the resident's clinical record. Interviews with the resident and facility staff, including the Activities Director and MDS Coordinator, confirmed the absence of a written care plan and a lack of documentation of activities provided to the resident. Additionally, the facility did not create a care plan for another resident, identified as Resident #39, who had specific medical needs including a right heel and right condition requiring Enhanced Barrier Precautions. The resident's clinical records showed physician orders for wound care and barrier precautions, but there was no corresponding care plan documented. Observations revealed that the necessary precautions were not in place, as there was no sign or isolation cart near the resident's door. Interviews with the MDS Coordinator and a Licensed Practical Nurse confirmed the absence of a care plan for the resident's medical conditions and precautions. The Director of Nursing and the Administrator were informed of these deficiencies, acknowledging that the lack of documentation indicated that the necessary care plans and activities were not implemented. The facility's failure to initiate and document comprehensive care plans for these residents highlights a significant oversight in meeting the residents' individualized care needs.
Plan Of Correction
N072 COMPREHENSIVE CARE PLANS 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #12, not having an activities care plan or documentation of activities participation. The Activities Director will be in-serviced about activities care-plans and documentation for activities participation. 2) In the allegation of Resident #39, not having a care plan for right heel or right, and no care plan for Enhanced Barrier Precautions. Missing Enhanced Barrier Precautions signage on the door, missing isolation cart near the resident's door. Nursing staff will be in-serviced about care and Enhanced Barrier Precautions care plans and protocols. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Activities Director will be in-serviced about activities care-plans and documentation for activities participation. Nursing staff will be in-serviced about care and Enhanced Barrier Precautions care plans and protocols. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date: