Deficiencies in Resident Care and Support
Penalty
Summary
The facility failed to provide adequate assistance during dining for two residents who required help with their meals. Observations revealed that one resident's meal trays were left untouched or barely eaten, with no staff present to assist, despite the resident's need for partial assistance. Interviews with staff indicated a misunderstanding of the resident's needs, as one CNA believed the resident could eat independently with minimal setup. Another resident also required encouragement and assistance with meals, but staff inconsistently provided the necessary support, as noted by the resident's family member. The facility also failed to maintain an ongoing activities program tailored to a resident's preferences. The resident expressed feelings of loneliness and a lack of engagement in activities, despite having specific interests such as going outside and participating in religious services. The Activities Director admitted to not documenting in-room activities and acknowledged that the resident's care plan lacked evidence of individualized activity planning. This oversight resulted in the resident not receiving the desired level of engagement and support. Additionally, the facility did not ensure timely administration of medications and proper medical care for several residents. One resident did not receive their Pleur-X drainage as ordered, leading to distress and potential health risks. Another resident experienced delays in medication administration, with some medications given up to two hours late. Furthermore, a resident did not have an abduction pillow in place as ordered, and another resident's nutritional needs were not met due to improper administration of enteral feeding. These deficiencies highlight a pattern of inadequate adherence to physician orders and care plans, compromising the residents' health and well-being.
Plan Of Correction
N201 FS RIGHT TO ADEQUATE AND APPROPRIATE HEALTH CARE 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 #1 having multiple meals where trays were not set up for the resident to eat. The resident ate minimal at all the observed meals. Nursing staff will be in-serviced to ensure ADLs are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. 2) In the allegation of Resident #275 needing help and encouragement during meals. Nursing staff will be in-service to ensure ADLs are followed for meal times for residents that need assistance, i.e. set up, assistance or encouragement with eating. 3) In the allegation of Resident #12, and 1 on 1 activities in room visits not being documented. The Activities Director will be in-serviced about activities 1 on 1 room visits and proper documentation of the visits. 4) In the allegation of Resident #73, and the Pleur-X not being drained on its schedule. And not following medication administration times of an hour prior or an hour post scheduled administration times. The Nursing staff will be in-serviced to follow doctors' orders regarding the drainage times of the Pleur-X. The Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. 5) In the allegation of Resident #481 having not received multiple medication at their prescribed times. Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. 6) In the allegation of Resident #46, and the resident's abduction pillow not being used. Nursing staff will be in-serviced to follow Doctor's orders and the use of assistive devices. 7) In the allegation of Resident #475, and the facility not receiving an order for almost 20 hours. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. 8) In the allegation of Resident #109, not for almost 22 hours and the tube-feeding not running at proper rate. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. 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: In-service will be conducted with nursing staff to ensure ADL are followed for mealtimes for residents that need assistance, i.e. set up, assistance or encouragement with eating. Activities Director will be in-serviced about activities 1 on 1 room visits and proper documentation of the visits. Nursing staff will be in-serviced to follow doctors' orders regarding the drainage times of the Pleur-X. Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. Nursing staff will be in-serviced to follow Doctor's orders and the use of assistive devices. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. 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: