Failure to Update Care Plan for Resident's Condition
Penalty
Summary
The facility failed to update the care plan for Resident R50 to accurately reflect the current status and care needs. Resident R50 was admitted to the facility with diagnoses of anemia, high blood pressure, and heart failure. Following a hospital stay from late December to the end of the month due to a fecal impaction, the care plan was not updated to include monitoring or management of fecal impaction or constipation. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan did not address the resident's condition related to fecal impaction or constipation. This oversight was identified during a review of the resident's care plan in mid-March, indicating a failure to revise the care plan after the resident's hospital stay and subsequent change in condition.
Plan Of Correction
The careplan for Resident #50 was updated and revised to reflect current status. Moving forward, the facility will ensure careplans are updated and revised timely to reflect current status. To identify other residents that have the potential to be affected, the Director of Nursing (DON)/designee reviewed all residents with a diagnosis or history of constipation and fecal impaction to ensure care plans are updated and revised timely. Corrections will be made as needed. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated IDT on the regulatory requirements of F657. To monitor and maintain ongoing compliance, the DON/designee will audit orders for any new constipation medications weekly x2 then monthly x 2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.