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 cognitive abilities being intact, as indicated by a Brief Interview of Mental Status score of 15, there was no documented activities care plan in the resident's clinical record. The resident expressed that they felt lonely and had lost a workbook during a room transfer, which was not replaced by the facility staff. Interviews with the Activities Director and MDS staff revealed a lack of coordination and documentation regarding the resident's activities care plan. 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 condition and required 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 confirmed the absence of necessary precautions, such as signage and isolation carts, during care procedures. Interviews with the MDS Coordinator and LPN involved in the resident's care highlighted a gap in the creation and implementation of care plans for the resident's identified needs. The deficiencies in care planning for both residents were acknowledged by facility staff, including the Director of Nursing and the Administrator, who confirmed that the lack of documentation indicated that the necessary care plans were not developed or implemented. This failure to document and execute comprehensive care plans for residents' activities and medical needs represents a significant oversight in the facility's care planning processes.
Plan Of Correction
Corrective action completion date: F656 DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN 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: